294 e-Letters

  • Fact checks and unwelcome consequences of fake COVID-19 vaccination news from India

    An article titled "Fake COVID-19 vaccination in India: a growing dilemma?" was published in this journal.1 This was followed by another article titled “Fake COVID-19 vaccines: scams hampering the vaccination drive in India and possibly other countries” in another journal.2 Though scientists in any part of the world have the right to comment or critique about COVID-19 vaccination in India or elsewhere, it is important to double-check the facts before publishing, especially if they are sensitive matters from another country. Many political decisions are made based on articles published in prestigious medical journals, which the public trusts and holds in high respect. In mid-September 2021, the UK announced new rules mandating that travellers from 17 countries do not have to self-isolate if they are fully vaccinated when they arrive in the UK, but the list did not include India.3 India reciprocated the UK COVID curbs by promulgating that UK nationals will have to undergo quarantine for ten days after arriving in India from the UK.4 Can we say that the articles like the present ones did not influence the action of the UK government? Subsequently, both the countries withdrew their curbs later.
    This article has not only cast doubts on the COVID-19 vaccines produced in India but also on the digital vaccine certificates that were given to the vaccinated. We'll dissect some of the mis- and disinformation, and other statements of this article. Of more than one...

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  • The impossible choices we ask patients to make

    This remarkable account of the successful treatment of two cases of Vaccine Induced Thrombosis with Thrombocytopenia(VITT) aged 86 and 38, respectively(1), is also remarkable for the fact that the second patient, aged 38, did not qualify for receipt of a vaccine other than the AstraZeneca vaccine. She failed to qualify because , either in April or in May 2021, Public Health England and Joint Committee on Vaccination and Immunisation(JCVI) issued a directive which stated "JCVI currently advises that it is preferable for adults aged < 30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID vaccine, if available"(2)(3). However, this recommendation did not apply to people aged 30-40(the age group of patient )(1), notwithstanding the fact that, on the 6th May 2021, headlines in the Independent had declared "Under 40s to be offered alternative to AstraZeneca vaccine over increased clot risk"(4).

    By the 30th July 2021, 411 cases of VITT had been documented, including 73 fatalities. In the age group 30-39 there were 51 cases of VITT, including 11 deaths(5). By the time this patient had been vaccinated, however, the BNT162b2(Pfizer) vaccine, and probably also the mRVA-1273(Moderna) vaccine must have been available as potential alternatives to the AstraZeneca vaccine. The Pfizer vaccine is 95% effective in preventing Covid-19(95% credible interval, 90.3 to 97.6).


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  • Confidence Intervals and proportion of older subjects in the trials

    In an otherwise excellent paper, the authors of the review of Covid-19 vaccine subtypes omitted to mention the confidence intervals of the statistics for vaccine efficacy(1). The importance of confidence intervals goes beyond .mere documentation of the possible range around the estimate.:the confidence interval also tells us about how stable the estimate is. A stable estimate is one that would be close to the stated value if the clinical trial were repeated. The same is not true of an unstable estimate.
    The authors also omitted to mention the proportion of older subjects in the respective trials. That in formation is a guide to the applicability of the trial results to the older population at large.
    The following are the answers to those questions:-
    Pfizer Vaccine
    Participants numbered 43,548 of whom 42.2% were aged >55.
    Vaccine efficacy amounted to 95%(95% Confidence Interval(CI): 90.35% to 97.6%(2).
    Moderna Vaccine:-
    Participants numbered 30,420 of whom 24.8% were aged 65 or more.
    Overall efficacy was 94.1%(95% CI, 89.3 to 96.8%)(3).
    Janssen Vaccine
    Participants numbered 39,291 of whom 33.5% were aged 60 or more.
    Overall efficacy amounted to 66.1%(95% CI 55% to 74.5%)
    AstraZeneca Vaccine
    In the subgroup who received two standard doses(the doses subsequently used in clinical practice) there were 8,895 participants. An important statistic is that 9% of the UK participants in that subgroup were...

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  • Response to Interarm BP difference

    Thank you for your valuable comments on our paper. According to the British and Irish Hypertension Society and the American Heart Association, clinicians should measure patients' blood pressure (BP) in both arms to diagnose possible cardiovascular anomalies and select the higher BP arm for subsequent measurement.1 The clinician is recommended to document patients' BP differences in both arms. Cardiovascular risks could be controlled more tightly when there is a persistent discrepancy of more than 15mmHg. Patients should be told which arm to use for future measurements.
    In our study, all participants had BP measured in both arms by the nurses upon recruitment. The arm with higher BP was documented and used in subsequent clinical and home BP measurements. Clinic nurses checked if participants had selected the correct arm at follow-up six weeks later.

  • Catchers and Leadership

    This was a most enjoyable read.

    "The role of wicket keeper is similar to being a catcher in baseball, and not usually associated with charisma or conventional leadership."

    In baseball, until November 2004, one of the longest and most famous droughts (years without winning the World Series) was that of the Boston Red Sox. It was said that they had been cursed for selling Babe Ruth, one of the greatest hitters in history, to their hated rivals, the New York Yankees. This was known as the Curse of the Bambino.

    But the historic curse was ended in 2004, when the Red Sox finally won the Series, under the exceptional leadership of their captain, the catcher Jason Varitek.

    As with the leadership of Mike Brearley in cricket, Jason Varitek in baseball showed that the exception proves the rule for catchers in every field.

  • Interarm difference in blood pressure

    It is axiomatic that , on initial assessment of a patient's blood pressure(BP), measurement should be recorded in both arms, and the higher of the two readings should be used for diagnosis and management(1). I would add that the arm with the higher blood pressure should be the arm from which home blood pressures are measured.

    Was that requirement fulfilled in the study evaluating knowledge and practice of home blood pressure monitoring?

    Awareness of interarm blood pressure informs the technique of blood pressure measurement. It also adds information about prognosis given the observation that "Every 10 mm Hg difference in systolic BP between arms conferred a mortality hazard of 1.24(95% Confidence Interval 1.01 to 1.52 after adjusting for average systolic BP and chronic kidney disease"(2). Arguably, the rationale for this observation comes from the meta analysis which showed that a difference of 15 mm Hg or more in systolic BP is associated with cerebrovascular disease and with peripheral vascular disease, and increased cardiovascular mortality, respectively(3).


    (1) Giles TG., Egan P
    Inter-arm difference in blood pressure may have serious research and clinical implications
    The Journal of Clinical Hypertension 2012;14:491-492
    (2) Agarwal R., Bunaye Z., Bekele DM
    Prognostic significance of bwteen-arm blood pressure differences
    (3)Clark CE., taylor R., Shore...

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  • Language Matters

    The article by Launer [1] raises the issue as to whether diagnostic labels are to be avoided as they can be stigmatising and judgemental. Within the article, the term ‘patient’ was used to convey the individual in receipt of the diagnosis. In recent years it has been suggested that ‘patient’ itself be avoided - as it can imply passivity in the face of the medical profession [2]. The word derives from the latin patiens, which means suffering; but also acquiescing, allowing and submitting. This latter connotation implies that a patient ‘receives’ the diagnosis - rather than being empowered to work with the doctor towards a meaningful interpretation of their symptoms and/or resolution of them. Use of the term ‘patient’ by healthcare workers may then lead to the medicalisation of thought towards the individual (semantic determinism). Conversely, surveys have suggested that people prefer to be called a patient [3]. This may reflect the lack of adequate alternative descriptors. To be a ‘patient’ may also be advantageous as it will then clarify to the health care professional and the legal system, the unique obligation they have to that individual. Perhaps, as with ‘diagnosis’, we should seek permission from the individuals themselves whether to refer to them as patients?

    1. Launer J. Postgrad Med J. 2021 Jan;97(1143):67-68. doi: 10.1136/postgradmedj-2020-139298.
    2. Cooper A., Kanumilli N., Hill J., Holt R.I.G et al. Diabetic Medicine. Language matters. Addressin...

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  • A reply to: Continuing Medical education during a pandemic: an academic institution’s experience

    Dear Editor,

    We read with great interest the article by Kanneganti et al. exploring ‘Continuing Medical Education during a pandemic: an academic institution’s experience’. As medical students at King’s College London (KCL) in the United Kingdom, our anecdotal experience parallels the findings of Kanneganti et al., who analyse the innovative changes to medical education in Singapore.(1) Although, Kanneganti et al. focus on continuing medical education (CME) for speciality training, as senior medical students we have found that the challenges of COVID-19 have also altered our intended medical education experience, specifically our clinical training.

    Kanneganti et al. mention the successful move of CME to online platforms, including Objective Structured Clinical Exams (OSCE) but acknowledge the difficulty in simulating clinical signs. Unlike the National University Hospital (NUH) in Singapore, KCL has chosen not to deliver OSCEs online and instead have adapted the traditional OSCE assessments into Clinical Workplace Examinations (CWE). This assesses clinical competency on one real-life patient where final year medical students undertake an in-depth history and clinical examination in a forty-five minute period. This is a stark contrast to the traditional multiple station format. Some may argue that this new format is unable to assess a wide variety of skills. Furthermore, it is far more challenging to standardise the CWE as students have different patients with...

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  • Burnout in the age of COVID-19 - Navigating medical school during a pandemic

    Dear Editor,

    We thank Dr Launer[1] for his reflection on burnout in the age of COVID-19. We would like to share our views on burnout as senior medical students. We believe that medical students are not immune to the pressures that have come from this pandemic and that there are important lessons for students about how to manage burnout before commencing their careers.

    As students, we look to our senior colleagues as examples of how to manage stress and maintain a healthy work life balance. We have seen the passion that most doctors carry with them despite the circumstances and hope to apply what we have observed in our future careers. In Dr Launer’s intriguing reflection, he mentions that junior doctors should be protected from the illusion that clinicians will remain consistently fired with enthusiasm from foundation training through to retirement. We believe this is a concept that should be taught from the very beginning of one’s career, namely in medical school.

    We remember as prospective medical students in secondary education, the discussions that surrounded pursuing a career in medicine being altogether the same - a rhetoric of saving lives and having a job that would be forever fulfilling. Although much of this is true, it seems throughout our education and inevitably as foundation doctors, the sugar-coating is removed and we are able to see what we were never told – that being a doctor can be hard, exhausting and frankly disappointing at ti...

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  • Medical Education during COVID Pandemic-Are we missing Bull's Eye

    We were pleased to read the very timely article in your esteemed journal titled “Continuing medical education during a pandemic: an academic institution’s experience”by Kanneganti et al 1 , The authors have given an in-depth description of various tools being used to impart medical education to postgraduate trainees in prevailing COVID crisis. We would like to commend the authors for the detailed analysis of impact of COVID pandemic on medical education and comment on evolving situation with current evidence so as to complement the issues raised by this thought provoking article.

    The unimaginable power of microcosmic CORONA virus has razed down human capability to master the universe and shown the vulnerability of Man’s vaunted display of power and arrogance.2 Medical education has not remained untouched by its impact. The Corona Virus has not only attacked our corporeal existence, it has affected us mentally, psychologically and institutionally. It has called for physical and social distancing that will make it difficult to hold classes for sizeable number of students to learn together. Although the benefits of direct student teacher interaction and real time two way feedback will be difficult to replicate at online forums 3 , still online classes seem to be the only preferred alternative to face to face education in current scenerio.2

    We at our institute are using WebX platform for online teaching activities. Teachers and students both can use th...

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