eLetters

249 e-Letters

  • The emerging role of new oral anticoagulants in HIT

    In their excellent review the authors drew attention to alternative oral anticoagulants to manage heparin-induced thrombocytopenia(HIT)(1). The American College of Chest Physicians guideline for HIT and HIT-associated thrombosis(HITT) cautions against premature transition to vitamin K antagonist therapy due to significant risk of warfarin-induced skin necrosis or development of venous limb gangrene(2). According to a recent review, the new oral anticoagulants(NOACs) are not burdened with that disadvantage, and their rapid onset of action generates a smooth transition to forward anticoagulation in patients with HIT/HITT. Furthermore, NOACs do not cross-react with HIT antibodies(3). That review encompassed data from 56 HIT/HITT patients subsequently treated with NOACs. Data were derived from 3 studies and 8 case reports. Mean age of the 56 patients was 70, twenty four had HIT, and thirty two had HITT. At the time of HIT/HITT diagnosis a nonheparin parenteral agent was initiated in 42, and the remaining 14 transitioned to NOACs straightaway. The NOACS used in the 56 patients were rivaroxaban, apixaban, and dabigatran in 54%, 29%, and 18% of cases, respectively. There were only 2 instances of recurrent thrombosis with NOAC therapy. Major bleeding occurred in 3 patients who did not appear to be on NOAC therapy at the time of the bleed.
    References
    (1) Prince M., Wenham T
    Heparin-induced thrombocytopemia
    Postgrad Med J 2018;94:453-547
    (2)Linkins L-A....

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  • A point of view: Diuretics and many dietary components significantly increase the risk of uric acid stone formation--Our major concern

    A point of view:
    Diuretics and many dietary components significantly increase the risk of uric acid stone formation--Our major concern.
    We read with interest and applauded the authors of the review article that mentions adjustment of potential pathophysiologic defects by pharmacotherapy and strongly recommends dietary modification for the prevention of uric stone recurrence (1).
    Two thirds of urate excretion occurs at the kidney, the remainder being excreted by the gut. Earlier studies have suggested that the urate is almost fully reabsorbed and that the urate excreted by the kidney is the result of tubular secretion. But more recent data suggests that secretion plays little part, and that excreted urate largely represents the filtered urate which escapes reabsorption. (2)
    Different diuretics are likely to have different effects on the renal handling of urate, but this has not been critically ascertained; patients receiving more powerful loop diuretics have a higher risk of developing gout than those receiving the weaker thiazides (3)
    Conceptually, a visit to a beer garden is dangerous for two reasons, the intake of purine rich food and drinks (beer) and the intake of fructose-rich soft drinks that blocks certain urate transporters that facilitate urate excretion (4).
    These are also associated with a number of common situations, such as the metabolic syndrome, which is correctable by changing to a low caloric diet, essential hypertensio...

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  • Exercise training does reverse left ventricular diastolic dysfunction in high risk subjects

    While it is true, as the authors assert, that there is limited data on exercise-induced reversal of cardiac remodeling, a recent study suggests that the cardiac effects of sedentary aging(in middle age) can be reversed by exercise training(1). In that study sixty one(48% male) healthy sedentary participants of mean age 53 were randomly assigned to either 2 years of exercise training(n=34) or attention control(control=27). In each subject measurements were taken to evaluate left ventricular stiffness. Maximal oxygen uptake was measured to quantify changes in fitness. Fifty three participants completed the study. Adherence to prescribed exercise sessions was 88% on average. As a result of exercise training left ventricular stiffness was significantly(p=0.0018)reduced(right/ downward shift in the end-diastolic pressure-volume relationships) in comparison with its pre-exercise value. This parameter did not change in the control group. Exercise significantly(p<0.001)increased the left ventricular end diastolic volume , whereas pulmonary capillary wedge pressure was unchanged, thereby generating significantly(p=0.007) greater stroke volume for any given filling pressure. The authors concluded that regular exercise training could provide protection against the future risk of heart failure with preserved ejection fraction by mitigating the risk of increase in cardiac stiffness attributable to a sedentary lifestyle(1). Accordingly, although we cannot influence the natu...

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  • Choice of words is crucial in effective communication

    Improving communication in decision-making is a worthy goal and the choice of words is crucial. Sayma and colleagues (1) have not considered the implications of some of their choices.

    Firstly, throughout the article they have used the word ‘advanced’ when describing decisions and care plans. This is a common misspelling but such issues are not superior formats but are care plans and decisions made in advance. Secondly, the authors mention ‘ceilings of care’ but do not explain that there are no ethical or legal permissions that allow care to be limited. This term is often misused when what is meant is a limit to treatment options. Finally the use of ‘escalation’ in care plans has been shown to be threatening to patients.(2) The term is too often used by clinicians without considering how this might be considered by patients.

    None of this should not detract from the value of the information provided during the study, but perhaps the authors will think carefully in future about their choice of words.

    Claud Regnard

    References
    1. Sayma M et al. Improving the use of treatment escalation plans: a quality improvement study. Postgrad Med J, 2018; doi: 10.1136/postgradmedj-2018-135699.
    2. Fritz Z, Fudd JP. Development of the Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a cross disciplinary approach. J Evaluation in Clinical Practice 2014; 21: 109-117.

  • The role of the dedicated nurse practitioner and other issues

    I agree with the authors of this excellent review that blood pressure(BP) measurement is often performed carelessly, and this is true both in primary and in secondary care. Although both doctors and nurses are responsible for this state of affairs, appropriately trained and dedicated(in terms of their job description) nurse practitioners are the ones who would be best placed to comply with the requirements for correct blood pressure measurement within "real world" time constraints(1). My proposal is to allocate a 10-15 minute slot for the nurse practitioner to measure the blood pressure in the relaxed environment of her own consulting room. Thereafter she can hand the patient over to the doctor to fulfil his own 10 minute or so time slot.
    Choice of diuretic medication for management of hypertension is the other issue specially relevant to the elderly. Although diuretics of first choice for antihypertensive treatment are typically either thiazides or indapamide, what needs to be recognised is that susceptibility to diuretic-related hyponatraemia involving those two drug subclasses is uniquely age-related, patients aged 60 or more being the ones most vulnerable to this complication(2)(3)(4)(5)(6). It is even conceivable that symptoms of drug-related hyponatraemia such as falls(2)(3) , might, on occasion, be misattributed to attainment of goal blood pressure, even if that target blood pressure is a modest one, with the consequence that antihypertensive...

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  • Response to: "Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys". A medical student perspective.

    Dear authors,

    Your recent report titled “Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys”(1) provided a thought-provoking read.

    As highlighted in your report, the uptake in training for specialties such as general practice continues to remain low. I strongly agree that in order to address this it is necessary to identify the factors that determine career choice in junior doctors. Furthermore, to encourage doctors to peruse undersubscribed specialties, it may be useful to identify the stage in training that the foundations of career choice are made. This may provide an opportunity to spark interest about these low uptake specialties in doctors who are still open minded about their future career.

    Your report demonstrates that even very early on in training, many doctors have a definite choice about their future specialty (1). Data collected from students at Brighton and Sussex medical school demonstrated that specialty choice is highly influenced by student’s experiences at medical school (2). I am a fourth year medical student, currently rotating through these various specialty placements and beginning to realistically consider my own personal career options. I too believe that the clinical phase of medical school may hold a unique window to motivate students to become interested in those undersubscribed specialties.

    Earlier this year a cohort study at the University of Dundee showed t...

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  • Promoting resilience among physicians is not an effective way to tackle burnout.

    Sir,
    In recent times, a lot has been spoken about the concept of ‘promoting physician resilience’ to tackle burnout.(1)(2) However, since the definitions and the strategies of resilience revolve around intrinsic factors, there is skepticism about this concept.(3) Now that the focus is being shifted towards the external factors influencing the burnout, this systematic review by Fox et al redefines ‘resilience’ in order to incorporate these external determinants into the domain of resilience.(4) While this letter agrees with the views portrayed by the authors of the review, it additionally discusses certain drawbacks of stressing the promotion of physician resilience.
    Though the resiliency training program, focusing on personal and psychological empowerment of physicians, temporarily improved the resiliency rates, it did not reduce the reported levels of fatigue among the participants.(2) Such resiliency methods in isolation do not seem to have a long-term benefits on the day-to-day practice in medicine. However, they may be handy even as a standalone strategy, in recharging the professionals in certain temporary situations like epidemic breakout, disaster scenario, warfare etc. Another drawback of repeated usage of resilience strategies is that it may render them ineffective with time, even in the same individual in whom the same strategies would work wonders earlier. In addition, repeated resiliency sessions could dilute the strive for perfection in medicine be...

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  • Re: [Medical research and audit skills training for undergraduates: An international analysis and student-focused needs assessment]

    Dear Sir,

    It was a pleasure reading Fitzgerald’s study on provision of research/audit opportunities and skills required to conduct such projects[1]. As medical-students, it was revealing to read statistics on how our contemporaries reported lack of formal research opportunities and training. As part of Europe’s largest medical school[2], one with a strong reputation that no doubt hinges on viable research output, we were not surprised by these results.

    Though we agree with the article’s conclusions, we’d like to offer our thoughts on factors affecting student output and improvements that could be made.

    From our experience, the main ways students are granted research opportunities are through Student Selected Components (SSCs) and intercalated BScs. Timescales for these are 5-6 months, with most having a shorter duration. Usually this is enough for a topic introduction, let alone information accumulation for an acceptable paper. Moreover, iBSc-derived research offers opportunities to access respected research teams and get better publications. We know students published in Nature due to their iBSc modules[3]. However, these modules are invariably oversubscribed, meaning students without sufficient marks are often excluded. Lastly, because of time and location demands on students during clinical years, it is likely most student publications come from research exposure during iBSc. The importance of this publication route needs further investigation....

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  • Response

    I was disappointed by this attempt to rebut my hypothesis.

    My hypothesis was not inchoate (OED “confused or incoherent”) as they obviously understood exactly what I wished to suggest – the conventional wisdom might be wrong or at least need some modification and that Carbon dioxide excretion may play a part in weight regulation.1

    We agree that the general public and health professionals are bewildered about weight regulation. That is not a reason to stop thinking and restate conventional wisdoms.

    We agree that “the majority of people they surveyed believed that that ”fat shed during weight loss was converted to energy rather than excreted as carbon dioxide and water.” That is not a reason to stop thinking and rely upon conventional wisdoms. I recall a paper that made the point that exhaled Carbon Dioxide might be relevant to fat loss.2 Indeed most people seem to assume that weight can be lost purely by energy production “raised metabolic rates” without a net excretion of heavy atoms but this is a conventional wisdom that is only correct in nuclear reactors in which E=mc2.

    Of course self –reporting of food intake is notoriously unreliable. But do we condemn as recidivists3 all those whose weigh loss plateaus on a diet? The same paper suggested a metabolic resistance to the maintenance of a reduced body weight. I merely provided a possible mechanism for this.

    We agree that “diets only succeed when the age-old advice to eat less and mov...

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  • Fake peer review: many faces

    Fake peer review: the many faces
    Viroj Wiwanitkit1
    1. Honorary Professor, Dr Dy Patil University, Pune Inida
    Email: wviroj@yahoo.com

    I read the recent publication by Cheung BMY with a great interest [1]. In fact, this problem is not uncommon and can be seen elsewhere.

    Reviews that seem overtly positive can be a clue for suspicious fake reviewing. It is the role of the journal editor to select the reviewer and consider the quality of the review. The fake reviewing might be by a non-existent (totally fake) person or a disguised reviewer. Sometimes, it can be a totally biased reviewer who is recommended by the submitting author.

    In addition, a similar problem can also be seen in academic presentations, proposal decisions, funding decisions, as well as academic position appointment decisions. In some underdeveloped countries, it is surprising that non-scientific reviewers can act as academic reviewers when academic work is under consideration. This reflects a poor standard and should be considered as an unacceptable misconduct.

    conflict of interest
    None

    References
    1. Cheung BMY. Fake peer review - too good to be true. Postgrad Med J. 2017 Jun 7. pii: postgradmedj-2016-134506.
    Conflict of Interest
    None declared

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