It is common to hear the inversion proposed by the author, and to consider the difficulties of the professional himself and not only those of the patient that we consider "difficult". And I think is very correct to insist on it again, and even put into context that "difficulty" of the doctor, achieved throughout her peculiar personal and professional itinerary, of which we often do not realize.
However, I believe that the approach made in the article is indebted to the extreme individualism that characterizes Western society and thought. I think it would be very interesting to face the problem from a more relational perspective, in which the "discomfort" of the patient could be adequately addressed and directed towards the appropriate interlocutor, in order to later focus the relationship between patient and doctor on what they both can really treat . I think the same should be said about the doctor's discomfort. In any case, I don't believe that we can justify a conception of the doctor-patient relationship in which any of them has the right to unload any type of discomfort that he treasures inside on his interlocutor.
And although we can assume a special responsibility of the doctor in the management of the encounter with the patient, this cannot exempt the patient from responsibility. The relationship must be built in both directions, each one from his/her responsibility and possibilities. Perhaps the problem is that,...
It is common to hear the inversion proposed by the author, and to consider the difficulties of the professional himself and not only those of the patient that we consider "difficult". And I think is very correct to insist on it again, and even put into context that "difficulty" of the doctor, achieved throughout her peculiar personal and professional itinerary, of which we often do not realize.
However, I believe that the approach made in the article is indebted to the extreme individualism that characterizes Western society and thought. I think it would be very interesting to face the problem from a more relational perspective, in which the "discomfort" of the patient could be adequately addressed and directed towards the appropriate interlocutor, in order to later focus the relationship between patient and doctor on what they both can really treat . I think the same should be said about the doctor's discomfort. In any case, I don't believe that we can justify a conception of the doctor-patient relationship in which any of them has the right to unload any type of discomfort that he treasures inside on his interlocutor.
And although we can assume a special responsibility of the doctor in the management of the encounter with the patient, this cannot exempt the patient from responsibility. The relationship must be built in both directions, each one from his/her responsibility and possibilities. Perhaps the problem is that, as a society, we care less and less about relationships themselves.
We agree that a nuclear catastrophe would result if these weapons were used. In this letter, we would like to add public health risks by military membership with other countries. After Russia’s invasion into Ukraine, there is increasing public support in Finland and Sweden for joining the North Atlantic Treaty Organization (NATO) (1, 2). Although we understand an advantage in Finland and Sweden for countering possible invasion by military membership, there is a risk of disadvantages of environmental contamination and epidemic spread caused by introducing foreign military bases. There will be ABC (atomic, biological, and chemical) risks for public health from introducing military bases. In fact, these risks have been observed in Okinawa. The prefecture of Japan has had U.S. military bases over the 77 years.
Atomic contamination happened in Okinawa because of the historical background of 1,400 nuclear weapons equipped in Okinawa in the 1960s. During the Cuban Missile Crisis, a nuclear missile was misfired from the U.S. military base in Naha, the local capital of Okinawa (3). There was also an accident in which an aircraft carrying a nuclear bomb fell from an aircraft carrier in the waters near Okinawa (4). The lost nuclear missile and bomb have never been removed and are still submerged in the waters near Okinawa. At the period of the Iraq War, the U.S. military conducted training to launch more than 1,000 depleted uranium bombs on an uninhabited island of Okinawa (5)...
We agree that a nuclear catastrophe would result if these weapons were used. In this letter, we would like to add public health risks by military membership with other countries. After Russia’s invasion into Ukraine, there is increasing public support in Finland and Sweden for joining the North Atlantic Treaty Organization (NATO) (1, 2). Although we understand an advantage in Finland and Sweden for countering possible invasion by military membership, there is a risk of disadvantages of environmental contamination and epidemic spread caused by introducing foreign military bases. There will be ABC (atomic, biological, and chemical) risks for public health from introducing military bases. In fact, these risks have been observed in Okinawa. The prefecture of Japan has had U.S. military bases over the 77 years.
Atomic contamination happened in Okinawa because of the historical background of 1,400 nuclear weapons equipped in Okinawa in the 1960s. During the Cuban Missile Crisis, a nuclear missile was misfired from the U.S. military base in Naha, the local capital of Okinawa (3). There was also an accident in which an aircraft carrying a nuclear bomb fell from an aircraft carrier in the waters near Okinawa (4). The lost nuclear missile and bomb have never been removed and are still submerged in the waters near Okinawa. At the period of the Iraq War, the U.S. military conducted training to launch more than 1,000 depleted uranium bombs on an uninhabited island of Okinawa (5). The radiation exposure in that area is still unclear because of unwillingness by governments of the U.S. and Japan to investigate it.
Biological (infectious) epidemics in Okinawa brought by the military base included congenital rubella syndrome in the 1960s and COVID-19 in the 2020s. Okinawa has been directly hit by infectious diseases prevalent in the US without normal quarantine for incoming foreign soldiers. Okinawa thus has a wide channel for the spread of infection to occur from abroad through the military bases. In 1965-69, the enormous number of Okinawan children were born with congenital rubella syndrome, compared to that in mainland Japan during the same period (6). Recently, in December 2021, COVID-19 took a sharp surge in Okinawa. Multiple outbreaks of infection occurred at the same time on the U.S. military bases and the infection spread to base employees and their families, who are mostly residents of Okinawa. This was a double spread of Omicron and Delta strains. The U.S. military reported later that their soldiers had not been tested for viruses before and after arrival to Okinawa and were not quarantined (7).
Chemical accidents came out in 1969, when an accidental release of VX gas inside an ammunition depot in Okinawa resulted in the hospitalization of 24 U.S. servicemen (8). Dioxin and other environmental contaminants were also buried within the soil of the base at the time of the Vietnam War (9). A recent chemical in question is PFAS (per- or poly-fluoroalkyl substances), a residual fluorinated organic compound consisting of several types often used on military bases as foam extinguishing agents. These were released from the bases. Groundwater and soil around bases have been contaminated at high concentrations (10).
These ABC risks are ongoing threats to public health in the local people of Okinawa. Regular inspection and surveillance is not allowed inside the bases, because of the military treaty between the U.S. and Japan. People of Finland and Sweden should carefully compare advantages and disadvantages of military membership which may lead to introducing a foreign military base. If they would allow the presence of a foreign military base, a rule for accepting regular inspection and surveillance should be provided to such bases.
3: Ota Masakatsu and Steve Rabson: U.S. Veterans Reveal 1962 Nuclear Close Call Dodged in Okinawa. The Asia-Pacific Journal. 30 March 2015. Accessed at: https://apjjf.org/-Steve-Rabson/4825/article.html
We have read the respective article entitled “overview of the possible treatment of hypoxia-induced obesity” by Sung Sik Choe and Jae Bum Kim(1). We were pleased to see how concisely they have linked hypoxia and hypoxia inducible factors with obesity. We agree to their problem statement, the gap analysis and the qualitative narrative review they have done to explain the process of inflammatory obesity.
Hypoxia is defined as a state in which the tissue oxygen levels are less than normal. The range of normal oxygen levels in tissue is 3% to 9% (2). A stable transcription factor is activated in a hypoxic state, known as the Hypoxia-inducible factor (HIF). Hypoxia inducible factor has a greater role in stabilizing oxygen levels by increasing circulating hemoglobin (3). It is a heterodimeric transcription factor as per its structure, further divided into alpha and beta subunits. In inflammatory induced obesity, the alpha subunit is found to have a prominent role. Hypoxia-inducible factor a is further divided into two units, HIF 1a and HIF 2a (4). These two units play an antagonistic role. HIF 1a plays a significant role in increasing inflammation in adipose tissues leading to an increase in the risk of inflammatory obesity. As per the location of the HIF 1A gene, it is mapped and located on human chromosome 14q21-24. It codes for the transcription factor HIF 1a, an essential factor for systemic oxygen homeostasis. Higher HIF 1a can indicate squamous ce...
We have read the respective article entitled “overview of the possible treatment of hypoxia-induced obesity” by Sung Sik Choe and Jae Bum Kim(1). We were pleased to see how concisely they have linked hypoxia and hypoxia inducible factors with obesity. We agree to their problem statement, the gap analysis and the qualitative narrative review they have done to explain the process of inflammatory obesity.
Hypoxia is defined as a state in which the tissue oxygen levels are less than normal. The range of normal oxygen levels in tissue is 3% to 9% (2). A stable transcription factor is activated in a hypoxic state, known as the Hypoxia-inducible factor (HIF). Hypoxia inducible factor has a greater role in stabilizing oxygen levels by increasing circulating hemoglobin (3). It is a heterodimeric transcription factor as per its structure, further divided into alpha and beta subunits. In inflammatory induced obesity, the alpha subunit is found to have a prominent role. Hypoxia-inducible factor a is further divided into two units, HIF 1a and HIF 2a (4). These two units play an antagonistic role. HIF 1a plays a significant role in increasing inflammation in adipose tissues leading to an increase in the risk of inflammatory obesity. As per the location of the HIF 1A gene, it is mapped and located on human chromosome 14q21-24. It codes for the transcription factor HIF 1a, an essential factor for systemic oxygen homeostasis. Higher HIF 1a can indicate squamous cell carcinomas and lead to several metabolic disorders. It can result in diabetes type II by causing insulin resistance (5).
Authors have very effectively stated the role of HIF subunits in obesity. Possible hypoxia-inducible factor 1a inactivating drugs can help cure such cases and reduce the chances of metabolic diseases. In this study role of HIF 1a in increasing levels of nitrous oxide is very well elaborated. However, HIF 1a role in activating inflammatory markers such as interleukins and cytokines should be further elaborated. HIF 1a has a more significant role therapeutically, so it can only be targeted in hypoxia-induced obesity cases other than parallel studying HIF 2a. Furthermore, the isoforms of HIF should also be studied in detail in future studies to bring a new treatment plan for obese subjects.
Reference:
1. Choe, S. S., & Kim, J. B. (2020). Hypoxia-inducible factors: new strategies for treatment of obesity-induced metabolic diseases. Postgraduate Medical Journal, 96(1138), 451-452.
2. Bradshaw, R. A., & Stahl, P. D. (2015). Encyclopedia of cell biology. Academic Press.
3. Windsor, J. S., & Rodway, G. W. (2007). Heights and haematology: the story of haemoglobin at altitude. Postgraduate medical journal, 83(977), 148-151.
4. Semenza, G. L., Shimoda, L. A., & Prabhakar, N. R. (2006, January). Regulation of gene expression by HIF-1. In Novartis Foundation Symposium (Vol. 272, p. 2). Chichester; New York; John Wiley; 1999.
5. Klatte, T., Seligson, D. B., Riggs, S. B., Leppert, J. T., Berkman, M. K., Kleid, M. D., ... & Belldegrun, A. S. (2007). Hypoxia-inducible factor 1α in clear cell renal cell carcinoma. Clinical Cancer Research, 13(24), 7388-7393.
oscar,m jolobe, retired geriatrician, British Medical Association
April 03, 2022
The occurrence of Henoch-Schonlein purpura after vaccination against COVID-19 infection(1) is, to a certain extent, predictable, given the fact that other subtypes of vasculitis have been reported after vaccination against this pathogen(2)(3). In one instance the temporal artery was involved, and the histological findings comprised infiltration with multinucleated giant cells, histiocytes, lymphocytes, and eosinophils. The patient had presented with bilateral headache, fever, fatigue, and myalgia, 2 days after receiving the second dose of a COVID-mRNA vaccine(2). In the second example granulomatous vasculitis involving the kidney occurred after administration of the AstraZeneca vaccine(3).
Even on its own, without the mediation of a vaccine, COVID-19 infection can trigger the occurrence of vasculitis(4). In the latter example a 71 year old woman presented with cough, fever, malaise and a pruritic rash on both legs, 2 weeks after her husband had been hospitalised for COVID-19 infection. The rash consisted of purpuric macules and papules , extending from ankles to the thighs. Histology revealed small-vessel vasculitis characterised by fibrinoid necrosis and infiltration by neutrophils.. Direct immunofluorescence revealed granular deposition of C3 within vessel walls. A nasopharyngeal swab was positive for COVID-19, using the reverse transcriptase polymerase chain reaction test(...
oscar,m jolobe, retired geriatrician, British Medical Association
April 03, 2022
The occurrence of Henoch-Schonlein purpura after vaccination against COVID-19 infection(1) is, to a certain extent, predictable, given the fact that other subtypes of vasculitis have been reported after vaccination against this pathogen(2)(3). In one instance the temporal artery was involved, and the histological findings comprised infiltration with multinucleated giant cells, histiocytes, lymphocytes, and eosinophils. The patient had presented with bilateral headache, fever, fatigue, and myalgia, 2 days after receiving the second dose of a COVID-mRNA vaccine(2). In the second example granulomatous vasculitis involving the kidney occurred after administration of the AstraZeneca vaccine(3).
Even on its own, without the mediation of a vaccine, COVID-19 infection can trigger the occurrence of vasculitis(4). In the latter example a 71 year old woman presented with cough, fever, malaise and a pruritic rash on both legs, 2 weeks after her husband had been hospitalised for COVID-19 infection. The rash consisted of purpuric macules and papules , extending from ankles to the thighs. Histology revealed small-vessel vasculitis characterised by fibrinoid necrosis and infiltration by neutrophils.. Direct immunofluorescence revealed granular deposition of C3 within vessel walls. A nasopharyngeal swab was positive for COVID-19, using the reverse transcriptase polymerase chain reaction test(4).
.
Comment
Vasculitic rash is one example of the overlap between COVID-19 and the vasculitides.
When a patient with giant cell arteritis presents with persistent cough and pyrexia(5)(6), the overlap between those symptoms and the symptoms of COVID-19 infection has the potential to lead to misdiagnosis or diagnostic delay. Remarkably, in the second case, published in 1994, the presenting feature included dry cough, breathlessness, fever, fatigue, conjunctivitis, otitis with deafness, and muscle pain in all four limbs. All these were symptoms that would, in subsequent years, be shown also to occur covid-19 infection. Furthermore, chest computed tomography showed irregular opacities in the upper lobes. It was the subsequent development of temporal and frontal headaches which triggered referral for temporal artery biopsy. This showed intimal fibrosis and infiltration of the vessel wall by lymphocytes and mononuclear cells. The patient’s condition improved rapidly after prescription of prednisone 60 mg daily(6).
I have no funding and no conflict of interest
References
(1)Wang SSY
Post BNT162b2 mRNA COVID-19 vaccination Henoch-Schonlein purpura
Postgrad Med J doi:10.1136/postgradmedj-2021-141407
Article in Press
(2)Greb CS., Aouhab Z., Sisbarro D., Panah E
A case of giant cell arteritis presenting after COVID-19 vaccination: Is it just a coincidence?
CUREUS DOI:10.7759/cureus.21608
(3)Gillion V., Jadoul M., Demoulin N., Aydin S., Devresse A
Granulomatous vasculitis after AstraZeneca anti-SARS-CoV-2 vaccine
Kidney International 2021;100:706-707
(4)Dominguez-Santa M., Diaz-Guimaraens B., Abellas P et al
Cutaneous small-vessel vasculitis associated with novel 2019 coronavirus SARS-CoV-2 infection(COVID-19).
JEADV 2020;34:e536-e537
(5)Olopade CO., Sekosan M., Schaufnagel DE
Giant cell arteritis manifesting as chronic cough and fever of unknown origin
Mayo Clinic Proceedings 1997;72:1048-1050
(6)Zenone T., Souquest P-J., Bohas C., Durand V., Bernard J-P
Unusual manifestations of giant cell arteritis: pulmonary nodules, cough, conjunctivitis and otitis with deafness
Eur Respir J 1994;7:2252-2254
Conflict of Interest
None declared
In the diagnosis of ST segment elevation MI, Qin et al (2021) had published an article which wherein the study was meticulously planned, analysed and interpreted in a comprehensive manner (1). The authors have used three ML algorithms to screen variables for prediction and evaluated six algorithms to select the best one that addressed the research question. As stated above the “aim was to use the constructed machine learning (ML) models as auxiliary diagnostic tools to improve the diagnostic accuracy of non-ST-elevation myocardial infarction (NSTEMI)”. Towards the end of a robust analysis, they were able to suggest an ML algorithm XGBoost as the best when compared to other algorithms and Logistic regression model as well.
In the process of addressing the above aim, they have compiled data retrospectively with a total of 2878 patients from January 2017 to December 2019. Of them 1409 patients were diagnosed with NSTEMI and 1469 patients were diagnosed with unstable angina pectoris. Thus the percentage of NSTEMI in the study was 48.9%. Does it reflect the hospital prevalence of NSTEMI? That is, if 100 patients visit the Cardiology department, what percent of them will have NSTEMI? Supposing that if this is 10%, then would the above identified variables of importance be the same? The probability of a patient having NSTEMI be the same? The ML algorithms are expected to work very well with 50% probability of disease. By not defining the sampling method, the process of ba...
In the diagnosis of ST segment elevation MI, Qin et al (2021) had published an article which wherein the study was meticulously planned, analysed and interpreted in a comprehensive manner (1). The authors have used three ML algorithms to screen variables for prediction and evaluated six algorithms to select the best one that addressed the research question. As stated above the “aim was to use the constructed machine learning (ML) models as auxiliary diagnostic tools to improve the diagnostic accuracy of non-ST-elevation myocardial infarction (NSTEMI)”. Towards the end of a robust analysis, they were able to suggest an ML algorithm XGBoost as the best when compared to other algorithms and Logistic regression model as well.
In the process of addressing the above aim, they have compiled data retrospectively with a total of 2878 patients from January 2017 to December 2019. Of them 1409 patients were diagnosed with NSTEMI and 1469 patients were diagnosed with unstable angina pectoris. Thus the percentage of NSTEMI in the study was 48.9%. Does it reflect the hospital prevalence of NSTEMI? That is, if 100 patients visit the Cardiology department, what percent of them will have NSTEMI? Supposing that if this is 10%, then would the above identified variables of importance be the same? The probability of a patient having NSTEMI be the same? The ML algorithms are expected to work very well with 50% probability of disease. By not defining the sampling method, the process of balancing 50:50 probability of disease and no disease might provide results that cannot be used in real life situation. As known in clinical epidemiology the positive predictive value of getting disease depends on the prevalence of disease. Therefore, the results have to be used with caution from this paper.
The variables (features) of importance help us to order the hierarchy of the study variables. However, this information is still not useful to be utilized such as relative risk or odds ratio. As suggested by Vollmer (2020) that clinically relevant research using ML and AI algorithm is often limited by transparency, reproducibility, ethics, and effectiveness. Unfortunately, the transparency is not available in algorithms such as SVM and XGBoost etc (2). While the patients and healthcare professionals require clinical prediction models to make decisions, the ML algorithms are “black box models” and the regression coefficients are not available. Though the ML algorithm provide the probability of getting the outcome of interest using appropriate codes in R, Python software, can we develop a prediction model similar to Glasgow coma score or APACHE II score using ML algorithms? As the ML algorithms are not easily computable like logistic regression etc., to predict the probability, we wonder the utility of using the variables of importance only. Do we need a model to assess the probability of getting outcome of interest besides the variables of importance with weights or just the variables of importance alone? How much trade off we would like to do in choosing between ML algorithms versus Logistic or Cox proportional hazard regression models?
Reference:
1. Qin L, Qi Q, Aikeliyaer A, Hou WQ, Zuo CX, Ma X. Machine learning algorithm can provide assistance for the diagnosis of non-ST-segment elevation myocardial infarction. Postgraduate Medical Journal 2022 Feb 16 Available from: https://pmj.bmj.com/content/early/2022/02/15/postgradmedj-2021-141329
2.Vollmer S, Mateen BA, Bohner G, Király FJ, Ghani R, Jonsson P, et al. Machine learning and artificial intelligence research for patient benefit: 20 critical questions on transparency, replicability, ethics, and effectiveness. BMJ. 2020 Mar 20;368:l6927.
Arguably, the consequences of Dr. Launer’s thoughtful reflection on listening to patients as ‘the essence of medical practice’ extend even beyond what he rightly describes as ’a vital step in creating more humane and equitable interactions in medicine’ (1). For those stories of ‘individual sickness’ are what medical historian Temkin (1963) describes as one of two major ways of understanding disease itself (2). This ‘physiological’ process-based approach to disease treats patients as a unique combination of factors leading to individual episodes of sickness. It has stood in historical opposition to the ‘ontological’ approach, where disease is understood as a ‘specific entity’ in and of itself that befalls an otherwise healthy person, and it is up to the physician to pluck out a homogenous disease from a pre-established reality happening within a passive patient. It is not that one way is ‘right,’ but there are historical examples where validating stories of sickness has led to more mature insights about the origins, causes, and treatment of disease by placing the individual patient in their unique context. Doing so seems particularly important if we are to take into account health inequities. An adequate view of humanistic medicine does not stop at the patient-physician relationship (3) and thus Launer’s principle of ‘giving not taking’ should extend into health systems and policy.
References
1 Launer J. Is taking a history outmoded? Why doctors should listen...
Arguably, the consequences of Dr. Launer’s thoughtful reflection on listening to patients as ‘the essence of medical practice’ extend even beyond what he rightly describes as ’a vital step in creating more humane and equitable interactions in medicine’ (1). For those stories of ‘individual sickness’ are what medical historian Temkin (1963) describes as one of two major ways of understanding disease itself (2). This ‘physiological’ process-based approach to disease treats patients as a unique combination of factors leading to individual episodes of sickness. It has stood in historical opposition to the ‘ontological’ approach, where disease is understood as a ‘specific entity’ in and of itself that befalls an otherwise healthy person, and it is up to the physician to pluck out a homogenous disease from a pre-established reality happening within a passive patient. It is not that one way is ‘right,’ but there are historical examples where validating stories of sickness has led to more mature insights about the origins, causes, and treatment of disease by placing the individual patient in their unique context. Doing so seems particularly important if we are to take into account health inequities. An adequate view of humanistic medicine does not stop at the patient-physician relationship (3) and thus Launer’s principle of ‘giving not taking’ should extend into health systems and policy.
References
1 Launer J. Is taking a history outmoded? Why doctors should listen to stories instead. Postgrad Med J. 2022 Mar;98(1157):236. doi: 10.1136/postgradmedj-2022-141516. PMID: 35181611.
2 Temkin O. The scientific approach to disease: Specific entity and individual sickness. In Scientific Change, ed. Crombie A. C., 1963, 629–47. New York/London: Heinemann (reprinted in Temkin 1977, 441–55).
3 Ferry-Danini J. A new path for humanistic medicine. Theor Med Bioeth. 2018 39(1):57-77. doi: 10.1007/s11017-018-9433-4. PMID: 29429022.
The delayed presentation of the association of left ventricular aneurysm(LVA) and ventricular septal rupture(VSR), reported by Patel et al(1), has its counterpart in the even longer delay, amounting to 3 months, documented in a 53 year old man who presented with increasing breathlessness and no history of chest pain. His delay in seeking medical attention was put down to to "apprehension sorrounding COVID-19". His electrocardiogram(ECG) showed ST segment elevation in the inferior leads. Coronary angiography showed severe multi-vessel disease including complete occlusion of the mid-right coronary artery. Transthoracic echocardiography(TTE) showed a basal inferior wall aneurysm and small ventricular septal rupture(VSR) with left- to -right shunt. Cardiac magnetic resonance imaging showed that the LVA measured 52 mm x 53 mm x 44 mm, with an associated mural thrombus. VSR and right-to-left shunt was confirmed. The patient experienced a successful, outcome from 3-vessel coronary artery bypass grafting, aneurysmectomy, and VSR patch repair(2).
Takotsubo cardiomyopathy(TTC) is another context for LVA(3) and for VSR(4), respectively. Furthermore, the association of ventricular free wall rupture(presumably a complication of ventricular pseudo aneurysm) and VSR can also be a feature of TTC(5). In the latter report a 73 year old woman presented with a 5 days history of chest pain and breathlessness. Her ECG showed ST elevation in leads V2-V5. TTE showed...
The delayed presentation of the association of left ventricular aneurysm(LVA) and ventricular septal rupture(VSR), reported by Patel et al(1), has its counterpart in the even longer delay, amounting to 3 months, documented in a 53 year old man who presented with increasing breathlessness and no history of chest pain. His delay in seeking medical attention was put down to to "apprehension sorrounding COVID-19". His electrocardiogram(ECG) showed ST segment elevation in the inferior leads. Coronary angiography showed severe multi-vessel disease including complete occlusion of the mid-right coronary artery. Transthoracic echocardiography(TTE) showed a basal inferior wall aneurysm and small ventricular septal rupture(VSR) with left- to -right shunt. Cardiac magnetic resonance imaging showed that the LVA measured 52 mm x 53 mm x 44 mm, with an associated mural thrombus. VSR and right-to-left shunt was confirmed. The patient experienced a successful, outcome from 3-vessel coronary artery bypass grafting, aneurysmectomy, and VSR patch repair(2).
Takotsubo cardiomyopathy(TTC) is another context for LVA(3) and for VSR(4), respectively. Furthermore, the association of ventricular free wall rupture(presumably a complication of ventricular pseudo aneurysm) and VSR can also be a feature of TTC(5). In the latter report a 73 year old woman presented with a 5 days history of chest pain and breathlessness. Her ECG showed ST elevation in leads V2-V5. TTE showed akinesis from mid to apical left ventricle. Right ventricular systolic function was also reduced, especially within the mid to apical segments. In addition, apical septal rupture was noted, and this was associated with left-to-right shunt. At the operating table the patient suddenly experienced hypotension, cardiac arrest, and pulseless electrical activity. Sternotomy revealed haemopericardium attributable to a 20 mm x 18 mm rupture within the right ventricular free wall. A VSR was also noted. In spite of ventriculoplasty and patch repair of the VSR the patient died 5 days post admission(5).
I have no funding and no conflict of interest.
References
(1)Patel NJ., Mundakkal A., Elrod-Gombash J., Changal K
Ventricular aneurysm and ventricular septal defect after myocardial infarction
Postgrad Med J Epub ahead of print doi:10.1136/postgradmedj-2020-139261
(2)Goraya MHN., Kalsoom S., Almas T et al
Simultaneous left ventricular aneurysm and ventricular septal rupture complicating delayed STEMI presentation: A case-based review of post-MI mechanical complications amid the COVID-19 pandemic
Journal of Investigative Medicine High Impact Case Reports 2021;9:1-12
(3)Miyata M., Nakazato K., Sakamoto N et al
Left ventricular plasty improved cardiac function in a case of takotsubo cardiomyopathy with persistent aneurysm
Journal of Cardiology Cases 2013;7:e133-e136
(4)Tsuji M., Isogai T., Okabe Y et al
Ventricular septal perforation: A rare but life-threatening complication associated with takotsubo syndrome
Internal Medicine
Intern Med Advance Publication
DOI:10.2169/internalmedicine.0014-17
(5)Sung J-M., Hong S-J., Chung I-H et al
Rupture of right ventricular free wall following ventricular septal rupture in Takotsubo Cardiomyopathy with right ventricular involvement
Yonsei Med J 2017;58:248-251
We read the rapid response from Dr Ravat titled “Sex Discrepancies in Work Life Balance” (3 January 2022), and thank them for their interest in this work. We shall address the points raised in turn.
Firstly, this rapid response states that “the authors conclude by suggesting a follow-up study to examine the impact of the COVID-19 pandemic on doctors’ reported work-life balance and home-life satisfaction.” This was merely a point made in the discussion. The main conclusion was that it is imperative that steps are taken to promote the wellbeing of doctors, as our study identifies a lack of work-life balance and identifies important barriers to this.[1]
Secondly, this rapid response discusses the possibility of selection bias in surveys of this nature – this was already acknowledged in the limitations of the paper. The lead authors of this study worked extremely hard to conduct and publish this work in adverse circumstances, including the COVID-19 pandemic, and successfully achieved 417 responses representing a wide variety of demographics (i.e. sex, age, professional grade, region of the UK, relationship status). Other such studies may only involve 20 respondents, and still provide useful data. Through studying the responses of 417 doctors across the UK, the authors have identified important barriers to work-life balance and home-life satisfaction that should be addressed to improve recruitment and retention of the medical workforce.
We read the rapid response from Dr Ravat titled “Sex Discrepancies in Work Life Balance” (3 January 2022), and thank them for their interest in this work. We shall address the points raised in turn.
Firstly, this rapid response states that “the authors conclude by suggesting a follow-up study to examine the impact of the COVID-19 pandemic on doctors’ reported work-life balance and home-life satisfaction.” This was merely a point made in the discussion. The main conclusion was that it is imperative that steps are taken to promote the wellbeing of doctors, as our study identifies a lack of work-life balance and identifies important barriers to this.[1]
Secondly, this rapid response discusses the possibility of selection bias in surveys of this nature – this was already acknowledged in the limitations of the paper. The lead authors of this study worked extremely hard to conduct and publish this work in adverse circumstances, including the COVID-19 pandemic, and successfully achieved 417 responses representing a wide variety of demographics (i.e. sex, age, professional grade, region of the UK, relationship status). Other such studies may only involve 20 respondents, and still provide useful data. Through studying the responses of 417 doctors across the UK, the authors have identified important barriers to work-life balance and home-life satisfaction that should be addressed to improve recruitment and retention of the medical workforce.
Thirdly, this rapid response appears to have confused statistical significance with qualitative significance.[2] We have not once claimed statistical significance in this qualitative study.
Fourthly, this rapid response suggests pre-determining content to search within the free-text responses/thematic analysis. This goes against the methodology we adopted for the thematic analysis and could introduce bias. Instead, the themes arose from the data, as stated in the methods, “Familiarisation of the data was achieved by reading and rereading the responses before open coding was performed. The codes were then combined or contrasted to identify relevant themes. This was an inductive and cyclical process, with extra care taken not to overlay professional judgements onto those of the respondents.”[3] This analysis revealed seven key themes, each with examples provided: unsocial working, rota issues, training issues, less-than-full-time working, location, leave and childcare.
Fifthly, this rapid response has implied that the authors were not mindful of framing bias when composing the survey questions. Many of the survey questions were neutral. In fact, the Likert-scale question of major importance was positively framed: “To what extent do you agree with the following statement? My training programme/job plan is associated with a satisfactory work-life balance.” We accept that perhaps sections of negatively and positively framed statements/questions could have been alternated to help offset framing bias. However, we do not think this has led to any false conclusions in this study.
To the best of our knowledge, this represents the first study assessing how the stresses of working life affect the personal lives and relationships of British doctors. Our study identified important barriers to work-life balance. Whilst we acknowledge the limitations of this study, we believe our conclusions are sound. We hope that this work serves as useful evidence to affect positive change, for the benefit of doctors, our families and loved ones, and our patients.
References
1. Parida S, Aamir A, Alom J, Rufai TA, Rufai SR. British doctors' work-life balance and home-life satisfaction: a cross-sectional study. Postgrad Med J. 2021 Dec 17:postgradmedj-2021-141338.
2. Morse JM. Qualitative Significance. Qual Health Res. 2004 Feb;14(2):151-2.
3. Chapman AL, Hadfield M, Chapman CJ. Qualitative research in healthcare: an introduction to grounded theory using thematic analysis. J R Coll Physicians Edinb 2015;45:201–5.
As Martha and Henry discussed the conditions of medical students in the United Kingdom, medical students in my country also faced a similar situation (https://pmj.bmj.com/content/97/1146/209). In March 2020, hospitals in Delhi started getting covid patients, all with international travel history. It was no sooner that the contagious virus had its hold over the national capital. We, as medical students, were posted in different medical specialties during our second, third and fourth years. Our clinical postings were canceled, and soon nationwide lockdown was declared.
In this never-experienced situation, our college started with online medical education. In the beginning, studying medicine virtually seemed impossible. What the eye doesn’t see, the mind doesn’t know, and vice versa. Gradually with time, online lectures became part of life. They were held on various platforms like Microsoft teams, google meets, and zoom. We could easily log in and not worry about running to lecture theatres.
The pandemic had a substantial negative impact on our clinical skills. We could not take history and examine live patients. We, as medical students, will have to live with this guilt forever.
The pandemic here in India saw exams getting postponed and graduations getting delayed. The neet pg exam that produces approximately 50000 and more postgraduate doctors in the country got postponed. We saw...
As Martha and Henry discussed the conditions of medical students in the United Kingdom, medical students in my country also faced a similar situation (https://pmj.bmj.com/content/97/1146/209). In March 2020, hospitals in Delhi started getting covid patients, all with international travel history. It was no sooner that the contagious virus had its hold over the national capital. We, as medical students, were posted in different medical specialties during our second, third and fourth years. Our clinical postings were canceled, and soon nationwide lockdown was declared.
In this never-experienced situation, our college started with online medical education. In the beginning, studying medicine virtually seemed impossible. What the eye doesn’t see, the mind doesn’t know, and vice versa. Gradually with time, online lectures became part of life. They were held on various platforms like Microsoft teams, google meets, and zoom. We could easily log in and not worry about running to lecture theatres.
The pandemic had a substantial negative impact on our clinical skills. We could not take history and examine live patients. We, as medical students, will have to live with this guilt forever.
The pandemic here in India saw exams getting postponed and graduations getting delayed. The neet pg exam that produces approximately 50000 and more postgraduate doctors in the country got postponed. We saw a considerable shortage of doctors in the country.
Apart from this, medical students were allowed to volunteer their services in covid wards and help in contact tracing. We also volunteered in mental health helplines. Ironically some of us also suffered from anxiety because of our career prospects.
Having a disaster training program is recommended highly in a country like India, where the healthcare system is still average. This shall prove to be a boon and aid in better preparedness.
The pandemic is known to have exacerbated the pre-existing sex inequalities amid healthcare workers. Prominent findings included the marked decline in female authored publications during the pandemic (1-3), concerns regarding the static pay gap (4) and higher levels of burnout for female frontline staff (5). Equal sex representation is difficult to achieve when the disproportionate strain on female trainees, often due to childcare burden, is regarded with relative apathy.
Parida et al. explored the barriers to work-life balance and home-life satisfaction through a cross-sectional study of 417 survey responses from UK doctors (6). The majority of respondents were found to hold negative views regarding work-life balance and home-life satisfaction. Female doctors, in particular, were more likely to switch specialty, enter less-than-full-time training, and delay buying a home, or having children. The authors conclude by suggesting a follow-up study to examine the impact of the COVID-19 pandemic on doctors’ reported work-life balance and home-life satisfaction. This would certainly be of great interest. However, it is important to consider the biases that manifest in survey-based study designs.
Surveys were distributed amongst a Facebook group, 'The Consulting Room', comprised of 7031 members. The authors acknowledged the likely inflating effects of selection bias, 'the inherent nature of a survey predisposes to respondents be...
The pandemic is known to have exacerbated the pre-existing sex inequalities amid healthcare workers. Prominent findings included the marked decline in female authored publications during the pandemic (1-3), concerns regarding the static pay gap (4) and higher levels of burnout for female frontline staff (5). Equal sex representation is difficult to achieve when the disproportionate strain on female trainees, often due to childcare burden, is regarded with relative apathy.
Parida et al. explored the barriers to work-life balance and home-life satisfaction through a cross-sectional study of 417 survey responses from UK doctors (6). The majority of respondents were found to hold negative views regarding work-life balance and home-life satisfaction. Female doctors, in particular, were more likely to switch specialty, enter less-than-full-time training, and delay buying a home, or having children. The authors conclude by suggesting a follow-up study to examine the impact of the COVID-19 pandemic on doctors’ reported work-life balance and home-life satisfaction. This would certainly be of great interest. However, it is important to consider the biases that manifest in survey-based study designs.
Surveys were distributed amongst a Facebook group, 'The Consulting Room', comprised of 7031 members. The authors acknowledged the likely inflating effects of selection bias, 'the inherent nature of a survey predisposes to respondents being a self-selecting group'. Respondents already concerned with work-life balance and home-life satisfaction may have been more likely to complete the survey.
The presumption of mutual independence is also erroneous. Facebook suggests groups based on friends and family. It is likely that members of the ‘The Consulting Room’ shared social circles, and some may have even shared households. This shared outlook may have further selected for particular responses.
Most importantly, authors ought to be mindful of framing bias when composing survey questions. Leading statements can heavily influence respondent views e.g. ‘My working pattern has caused difficulties in my personal relationships’. This can be challenging to avoid when using Likert scales to agree/disagree with given statements, but can be offset by interspersing contrasting, ‘positively framed’ statements/questions.
In spite of these biases, the free-text questions were a useful means of establishing particular barriers faced by doctors, and potential solutions. It would be interesting to ascertain whether the themes drawn from the responses varied depending on age and sex.
Finally, medical literature should avoid colloquial use of the term ‘significance’. Parida et al. wrote that a ‘significant proportion of respondents reported delaying major life event’ and that ‘there was no significant difference in leaving training positions or satisfactory work–life balance between the two sexes’. In the absence of statistical analyses, such conclusions may be vulnerable to misinterpretation.
Kind Regards.
Bibliography
1. Squazzoni F, Bravo G, Grimaldo F, García-Costa D, Farjam M, Mehmani B. Gender gap in journal submissions and peer review during the first wave of the COVID-19 pandemic. A study on 2329 Elsevier journals. PLOS ONE. 2021;16(10):e0257919.
2. Muric G, Lerman K, Ferrara E. Gender Disparity in the Authorship of Biomedical Research Publications During the COVID-19 Pandemic: Retrospective Observational Study. Journal of Medical Internet Research. 2021;23(4):e25379.
3. Viglione G. Are women publishing less during the pandemic? Here’s what the data say. Nature. 2020;581(7809):365-6.
4. Woodhams C, Dacre J, Parnerkar I, Sharma M. Pay gaps in medicine and the impact of COVID-19 on doctors' careers. The Lancet. 2021;397(10269):79-80.
5. Rimmer A. Covid-19: Female doctors felt compelled to step up during the pandemic, says BMA. BMJ. 2021;372:n658.
6. Parida S, Aamir A, Alom J, Rufai TA, Rufai SR. British doctors’ work–life balance and home-life satisfaction: a cross-sectional study. Postgraduate Medical Journal. 2021:postgradmedj-2021-141338.
It is common to hear the inversion proposed by the author, and to consider the difficulties of the professional himself and not only those of the patient that we consider "difficult". And I think is very correct to insist on it again, and even put into context that "difficulty" of the doctor, achieved throughout her peculiar personal and professional itinerary, of which we often do not realize.
Show MoreHowever, I believe that the approach made in the article is indebted to the extreme individualism that characterizes Western society and thought. I think it would be very interesting to face the problem from a more relational perspective, in which the "discomfort" of the patient could be adequately addressed and directed towards the appropriate interlocutor, in order to later focus the relationship between patient and doctor on what they both can really treat . I think the same should be said about the doctor's discomfort. In any case, I don't believe that we can justify a conception of the doctor-patient relationship in which any of them has the right to unload any type of discomfort that he treasures inside on his interlocutor.
And although we can assume a special responsibility of the doctor in the management of the encounter with the patient, this cannot exempt the patient from responsibility. The relationship must be built in both directions, each one from his/her responsibility and possibilities. Perhaps the problem is that,...
We agree that a nuclear catastrophe would result if these weapons were used. In this letter, we would like to add public health risks by military membership with other countries. After Russia’s invasion into Ukraine, there is increasing public support in Finland and Sweden for joining the North Atlantic Treaty Organization (NATO) (1, 2). Although we understand an advantage in Finland and Sweden for countering possible invasion by military membership, there is a risk of disadvantages of environmental contamination and epidemic spread caused by introducing foreign military bases. There will be ABC (atomic, biological, and chemical) risks for public health from introducing military bases. In fact, these risks have been observed in Okinawa. The prefecture of Japan has had U.S. military bases over the 77 years.
Atomic contamination happened in Okinawa because of the historical background of 1,400 nuclear weapons equipped in Okinawa in the 1960s. During the Cuban Missile Crisis, a nuclear missile was misfired from the U.S. military base in Naha, the local capital of Okinawa (3). There was also an accident in which an aircraft carrying a nuclear bomb fell from an aircraft carrier in the waters near Okinawa (4). The lost nuclear missile and bomb have never been removed and are still submerged in the waters near Okinawa. At the period of the Iraq War, the U.S. military conducted training to launch more than 1,000 depleted uranium bombs on an uninhabited island of Okinawa (5)...
Show MoreDear Editor,
We have read the respective article entitled “overview of the possible treatment of hypoxia-induced obesity” by Sung Sik Choe and Jae Bum Kim(1). We were pleased to see how concisely they have linked hypoxia and hypoxia inducible factors with obesity. We agree to their problem statement, the gap analysis and the qualitative narrative review they have done to explain the process of inflammatory obesity.
Show MoreHypoxia is defined as a state in which the tissue oxygen levels are less than normal. The range of normal oxygen levels in tissue is 3% to 9% (2). A stable transcription factor is activated in a hypoxic state, known as the Hypoxia-inducible factor (HIF). Hypoxia inducible factor has a greater role in stabilizing oxygen levels by increasing circulating hemoglobin (3). It is a heterodimeric transcription factor as per its structure, further divided into alpha and beta subunits. In inflammatory induced obesity, the alpha subunit is found to have a prominent role. Hypoxia-inducible factor a is further divided into two units, HIF 1a and HIF 2a (4). These two units play an antagonistic role. HIF 1a plays a significant role in increasing inflammation in adipose tissues leading to an increase in the risk of inflammatory obesity. As per the location of the HIF 1A gene, it is mapped and located on human chromosome 14q21-24. It codes for the transcription factor HIF 1a, an essential factor for systemic oxygen homeostasis. Higher HIF 1a can indicate squamous ce...
oscar,m jolobe, retired geriatrician, British Medical Association
Show MoreApril 03, 2022
The occurrence of Henoch-Schonlein purpura after vaccination against COVID-19 infection(1) is, to a certain extent, predictable, given the fact that other subtypes of vasculitis have been reported after vaccination against this pathogen(2)(3). In one instance the temporal artery was involved, and the histological findings comprised infiltration with multinucleated giant cells, histiocytes, lymphocytes, and eosinophils. The patient had presented with bilateral headache, fever, fatigue, and myalgia, 2 days after receiving the second dose of a COVID-mRNA vaccine(2). In the second example granulomatous vasculitis involving the kidney occurred after administration of the AstraZeneca vaccine(3).
Even on its own, without the mediation of a vaccine, COVID-19 infection can trigger the occurrence of vasculitis(4). In the latter example a 71 year old woman presented with cough, fever, malaise and a pruritic rash on both legs, 2 weeks after her husband had been hospitalised for COVID-19 infection. The rash consisted of purpuric macules and papules , extending from ankles to the thighs. Histology revealed small-vessel vasculitis characterised by fibrinoid necrosis and infiltration by neutrophils.. Direct immunofluorescence revealed granular deposition of C3 within vessel walls. A nasopharyngeal swab was positive for COVID-19, using the reverse transcriptase polymerase chain reaction test(...
In the diagnosis of ST segment elevation MI, Qin et al (2021) had published an article which wherein the study was meticulously planned, analysed and interpreted in a comprehensive manner (1). The authors have used three ML algorithms to screen variables for prediction and evaluated six algorithms to select the best one that addressed the research question. As stated above the “aim was to use the constructed machine learning (ML) models as auxiliary diagnostic tools to improve the diagnostic accuracy of non-ST-elevation myocardial infarction (NSTEMI)”. Towards the end of a robust analysis, they were able to suggest an ML algorithm XGBoost as the best when compared to other algorithms and Logistic regression model as well.
Show MoreIn the process of addressing the above aim, they have compiled data retrospectively with a total of 2878 patients from January 2017 to December 2019. Of them 1409 patients were diagnosed with NSTEMI and 1469 patients were diagnosed with unstable angina pectoris. Thus the percentage of NSTEMI in the study was 48.9%. Does it reflect the hospital prevalence of NSTEMI? That is, if 100 patients visit the Cardiology department, what percent of them will have NSTEMI? Supposing that if this is 10%, then would the above identified variables of importance be the same? The probability of a patient having NSTEMI be the same? The ML algorithms are expected to work very well with 50% probability of disease. By not defining the sampling method, the process of ba...
Arguably, the consequences of Dr. Launer’s thoughtful reflection on listening to patients as ‘the essence of medical practice’ extend even beyond what he rightly describes as ’a vital step in creating more humane and equitable interactions in medicine’ (1). For those stories of ‘individual sickness’ are what medical historian Temkin (1963) describes as one of two major ways of understanding disease itself (2). This ‘physiological’ process-based approach to disease treats patients as a unique combination of factors leading to individual episodes of sickness. It has stood in historical opposition to the ‘ontological’ approach, where disease is understood as a ‘specific entity’ in and of itself that befalls an otherwise healthy person, and it is up to the physician to pluck out a homogenous disease from a pre-established reality happening within a passive patient. It is not that one way is ‘right,’ but there are historical examples where validating stories of sickness has led to more mature insights about the origins, causes, and treatment of disease by placing the individual patient in their unique context. Doing so seems particularly important if we are to take into account health inequities. An adequate view of humanistic medicine does not stop at the patient-physician relationship (3) and thus Launer’s principle of ‘giving not taking’ should extend into health systems and policy.
References
1 Launer J. Is taking a history outmoded? Why doctors should listen...
Show MoreThe delayed presentation of the association of left ventricular aneurysm(LVA) and ventricular septal rupture(VSR), reported by Patel et al(1), has its counterpart in the even longer delay, amounting to 3 months, documented in a 53 year old man who presented with increasing breathlessness and no history of chest pain. His delay in seeking medical attention was put down to to "apprehension sorrounding COVID-19". His electrocardiogram(ECG) showed ST segment elevation in the inferior leads. Coronary angiography showed severe multi-vessel disease including complete occlusion of the mid-right coronary artery. Transthoracic echocardiography(TTE) showed a basal inferior wall aneurysm and small ventricular septal rupture(VSR) with left- to -right shunt. Cardiac magnetic resonance imaging showed that the LVA measured 52 mm x 53 mm x 44 mm, with an associated mural thrombus. VSR and right-to-left shunt was confirmed. The patient experienced a successful, outcome from 3-vessel coronary artery bypass grafting, aneurysmectomy, and VSR patch repair(2).
Show MoreTakotsubo cardiomyopathy(TTC) is another context for LVA(3) and for VSR(4), respectively. Furthermore, the association of ventricular free wall rupture(presumably a complication of ventricular pseudo aneurysm) and VSR can also be a feature of TTC(5). In the latter report a 73 year old woman presented with a 5 days history of chest pain and breathlessness. Her ECG showed ST elevation in leads V2-V5. TTE showed...
Dear Editor,
We read the rapid response from Dr Ravat titled “Sex Discrepancies in Work Life Balance” (3 January 2022), and thank them for their interest in this work. We shall address the points raised in turn.
Firstly, this rapid response states that “the authors conclude by suggesting a follow-up study to examine the impact of the COVID-19 pandemic on doctors’ reported work-life balance and home-life satisfaction.” This was merely a point made in the discussion. The main conclusion was that it is imperative that steps are taken to promote the wellbeing of doctors, as our study identifies a lack of work-life balance and identifies important barriers to this.[1]
Secondly, this rapid response discusses the possibility of selection bias in surveys of this nature – this was already acknowledged in the limitations of the paper. The lead authors of this study worked extremely hard to conduct and publish this work in adverse circumstances, including the COVID-19 pandemic, and successfully achieved 417 responses representing a wide variety of demographics (i.e. sex, age, professional grade, region of the UK, relationship status). Other such studies may only involve 20 respondents, and still provide useful data. Through studying the responses of 417 doctors across the UK, the authors have identified important barriers to work-life balance and home-life satisfaction that should be addressed to improve recruitment and retention of the medical workforce.
...
Show MoreDear editor,
As Martha and Henry discussed the conditions of medical students in the United Kingdom, medical students in my country also faced a similar situation (https://pmj.bmj.com/content/97/1146/209). In March 2020, hospitals in Delhi started getting covid patients, all with international travel history. It was no sooner that the contagious virus had its hold over the national capital. We, as medical students, were posted in different medical specialties during our second, third and fourth years. Our clinical postings were canceled, and soon nationwide lockdown was declared.
In this never-experienced situation, our college started with online medical education. In the beginning, studying medicine virtually seemed impossible. What the eye doesn’t see, the mind doesn’t know, and vice versa. Gradually with time, online lectures became part of life. They were held on various platforms like Microsoft teams, google meets, and zoom. We could easily log in and not worry about running to lecture theatres.
The pandemic had a substantial negative impact on our clinical skills. We could not take history and examine live patients. We, as medical students, will have to live with this guilt forever.
The pandemic here in India saw exams getting postponed and graduations getting delayed. The neet pg exam that produces approximately 50000 and more postgraduate doctors in the country got postponed. We saw...
Show MoreDear Editor,
The pandemic is known to have exacerbated the pre-existing sex inequalities amid healthcare workers. Prominent findings included the marked decline in female authored publications during the pandemic (1-3), concerns regarding the static pay gap (4) and higher levels of burnout for female frontline staff (5). Equal sex representation is difficult to achieve when the disproportionate strain on female trainees, often due to childcare burden, is regarded with relative apathy.
Parida et al. explored the barriers to work-life balance and home-life satisfaction through a cross-sectional study of 417 survey responses from UK doctors (6). The majority of respondents were found to hold negative views regarding work-life balance and home-life satisfaction. Female doctors, in particular, were more likely to switch specialty, enter less-than-full-time training, and delay buying a home, or having children. The authors conclude by suggesting a follow-up study to examine the impact of the COVID-19 pandemic on doctors’ reported work-life balance and home-life satisfaction. This would certainly be of great interest. However, it is important to consider the biases that manifest in survey-based study designs.
Surveys were distributed amongst a Facebook group, 'The Consulting Room', comprised of 7031 members. The authors acknowledged the likely inflating effects of selection bias, 'the inherent nature of a survey predisposes to respondents be...
Show MorePages