42 e-Letters

published between 2019 and 2022

  • We need a more relational perspective

    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,...

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  • ABC risks for public health by introducing foreign military bases

    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)...

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  • HIF isoforms and personlized anti-obesity strategies ?

    Dear 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.
    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...

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  • Other examples of COVID-19-related vasculitis

    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(...

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  • Utility of ML algorithms: Are we predicting the outcome or finding the risk factors.

    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...

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  • Disease concepts at stake in stories of individual sickness

    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.


    1 Launer J. Is taking a history outmoded? Why doctors should listen...

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  • The delayed presentation of mechanical complications of myocardial infarction

    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...

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  • Authors' response to Sex Discrepancies in Work Life Balance

    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.


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  • Perspective of Online medical education

    Dear 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...

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  • Sex Discrepancies in Work Life Balance

    Dear 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...

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