Recent letters
Displaying 1-10 letters out of 4159 published
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I enjoyed the case presentation and practice discussion of a 66 year old woman with spontaneous rib fracture which focused quickly on the importance of ruling out metastatic cancer and further discussion of other causes of nontraumatic rib fracture.(1) I would like to add to the differential diagnosis the possibility of intimate partner violence (IPV) which was not explored in this case. In a recent cross-sectional study involving nearly 3000 women being assessed at one of 12 orthopedic clinics in Canada, USA, Netherlands, Denmark and India, the PRevalence of Abuse and Intimate partner violence Surgical Evaluation (PRAISE) investigators found that 1 out of 6 woman surveyed had a history of IPV in the past 12 months, 1 out of 3 had suffered IPV in their lifetime, and 1 in 50 women were attending the orthopedic clinic as a direct result of IPV.(2) In an earlier study carried out at the Minnesota Domestic Abuse Program, investigators identified chest injuries in 8% of women assessed at the program, the majority of which were rib fractures.(3)
In the PRAISE study, of the women who were assessed directly because of an IPV injury, only 14% had ever been asked by a provider in the healthcare system whether they were subject to IPV.(2) While the current case is fictitious, and describes a "spontaneous" or "nontraumatic" rib fracture, it should serve to remind primary care providers and specialists alike that there are many opportunities to engage in conversations with patients about IPV. To quote the Roman fabulist Phaedrus, "Things are not always what they seem; first appearances deceive many." (4)
References
1. Harris SR. A 66-year-old woman with spontaneous rib fracture. CMAJ. 2015 Sep 22;187(13):988-9.
2. PRAISE Investigators, Sprague S, Bhandari M, Della Rocca GJ, Goslings JC, Poolman RW, Madden K, Simunovic N, Dosanjh S, Schemitsch EH. Prevalence of abuse and intimate partner violence surgical evaluation (PRAISE) in orthopaedic fracture clinics: a multinational prevalence study. Lancet. 2013 Sep 7;382(9895):866-76.
3. Bhandari M, Dosanjh S, Tornetta P 3rd, Matthews D; Violence Against Women Health Research Collaborative. Musculoskeletal manifestations of physical abuse after intimate partner violence. J Trauma. 2006 Dec;61(6):1473-9.
4. The Comedies of Terence, and the Fables of Phaedrus. Literally translated into English prose. Henry Thomas Riley and Christopher Smart. George Bell & Sons, York Street, Covent Garden, London, 1887.
Conflict of Interest:
None declared
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CIHR MD/PhD Cuts: Depleting The Physician -Scientist Pipeline At What Cost?
Submit responseThe recent announcement of cuts to CIHR's MD-PhD program grants is disheartening. These funds represent only 0.15% of CIHR's $1.3 billion operating budget. Considering that over 52% of trainees relied on CIHR MD- PhD studentships in 2010, this will undoubtedly have a profound impact on physician-scientist training in Canada [1]. This is especially concerning in light of the disturbing trend showing a decline in the number of physician-scientists [2].
In response to the volatile funding climate, we surveyed McGill University's MD-PhD program alumni to assess its success in producing physician-scientists. Since 1989, 41 students have completed the program (response rate = 73.2%) with 76.7% of them being retained in Canada. Of the 15 post-training alumni, 66.7% have become physician-scientists or pure scientists. These individuals are well-funded, with 88.9% as primary investigators on a research grant, 55.5% holding operating grants from federal funding bodies (eg. CIHR, NIH) and 77.8% holding multiple ongoing grants. They have a mean H-index of 18 - a substantial number given the average H-indices in science, based on an Canadian education policy think tank [3], are lower than 10. There are several examples of alumni who have made landmark discoveries that have been rapidly translated to the clinical domain [4, 5]. Considering these individuals have only held academic positions for 4-15 years, they have demonstrated significant research productivity as early- to mid-career physician-scientists.
Although the study population is small, our survey depicts the success of this training route in producing impactful physician- scientists. As an intermediately sized program with a typical curriculum, our findings may be generalizable to other Canadian MD-PhD programs.
Many of the milestones in Canadian health research were set forth by physician-scientists: Drs. Banting and Best discovered insulin; Dr. Wilder Penfield performed the first neurosurgery to treat epilepsy; Dr. Vera Peters spearheaded the use of radiation to cure Hodgkin's disease; and Dr. Phil Gold discovered the carcinoembryonic antigen tumor marker. Ultimately, the shortsightedness of CIHR's recent decision has the potential to deplete the repertoire of next-generation physician- scientists in Canada. For this reason, we sincerely urge CIHR to reverse the funding cuts to MD-PhD programs.
References
1. Appleton CT, Belrose J, Ward MR, Young FB. Strength in numbers: growth of Canadian clinician investigator training in the 21st century. Clinical and investigative medicine Medecine clinique et experimentale. 2013;36(4):E163-9.
2. Physician-Scientist Workforce Working Group Report In: NIH, editor. 2014.
3. Back to Bibliometrics: Higher Education Strategy Associates (HESA); 2015 [cited 2015]. Available from: http://higheredstrategy.com/page/2/?s=h -index.
4. Nielsen T, Wallden B, Schaper C, Ferree S, Liu S, Gao D, et al. Analytical validation of the PAM50-based Prosigna Breast Cancer Prognostic Gene Signature Assay and nCounter Analysis System using formalin-fixed paraffin-embedded breast tumor specimens. BMC cancer. 2014;14:177.
5. Jermyn M, Mok K, Mercier J, Desroches J, Pichette J, Saint-Arnaud K, et al. Intraoperative brain cancer detection with Raman spectroscopy in humans. Sci Transl Med. 2015;7(274):274ra19.
Conflict of Interest:
None declared
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Counter Points
Submit responseThe commentary from Dr. Dan Gregson et al. signals that there will be no change in the medical community in the treatment of Lyme disease and attitudes around it despite all the hopes of the public and politicians after the passage of Bill C-442. The Canadian testing is deeply flawed and woefully inadequate. It does a great disservice to the patients and there is not enough research being done on ticks and the many pathogens that they can carry. Their analysis failed to inform Canadians that the Government-approved tests in Canada come from for-profit corporations who are dictated to by the United States Center for Disease Control (CDC). The Association of Medical Microbiology and Infectious Disease Canada (AMMI) failed to point out that there is no 'gold standard serology' for Lyme disease. Canadian doctors are discouraged from treating patients even though it is clear that false negative test results are at least as important to Canadians as false positive tests and subsequently much more harmful.
The implication is that the private, certified licensed labs run by PhD immunologists and microbiologists are doing something wrong simply because they expand their tests to more than one genotype of Borrelia. Lyme disease is a borreliosis caused by multiple strains. All tests have advantages and disadvantages. Patients need the data from their tests along with a note from the laboratory stating that "a negative test result doesn't necessarily mean you do not have Lyme disease. If symptoms persist or worsen return to your health care provider for additional tests or treatment." Doctors must learn how to read Western blot bands not just receive a yes/no reply. The patient's misery is obvious when they receive a negative result from a provincial lab and a positive result from an accredited lab in the US.
The U.S. Dearborn surveillance criteria were contentious in 1994 and they are contentious today. The AMMI leans regularly towards emphasis on serology and known endemic areas while denying chronic persistent infection and leaving the patients sick with labels like fibromyalgia, chronic fatigue syndrome and MS which have nothing to do with defining the disease. Infectious Disease doctors across Canada regularly refuse to see patients who are referred by other physicians, simply because they do not have a positive Canadian blood test.
It's time to revisit the Dearborn criteria and for the AMMI to stress the importance of clinical diagnosis rather than imply that doctors listening to patients and using their clinical skills are being misled. Why doesn't the AMMI ask the national lab to release western blot banding patterns? Doctors receive data from other lab reports along with the hospital's normal range of results. They review these while listening to their patients to come up with an informed diagnosis and treatment plan. But, in cases of Lyme borreliosis the diagnosis is removed from the physician and given to the lab.
The AMMI would have us believe that thousands of patients with similar stories are all delusional. If it were just a few cases you could call it anecdotal; when it is thousands of cases, it is evidence. They fail to account for the reasons why thousands cross the border to seek treatment and most seem to get better. It is true that not everyone fully recovers. The AMMI fail to explain why Canada has the highest rate of MS in the world and the lowest rate of LB. Further, we need to have a broader discussion and willingness to look at alternative explanations as to why patients have ongoing symptoms after treatment for LB, and more inclusive membership on panels that make up treatment guidelines.
There now is some consensus on the early treatment of this disease. The problems arise when people are unaware that they have been bitten by an infected tick and don't have a diagnostic EM rash. The Borrelia can dampen the immune response and move so rapidly into cells and immune protected locations like the brain that serologic tests are usually negative. This bacterium is well adapted to parasitize like its close cousin Treponema. It hates our fluids and that is why it is so difficult to find even with today's techniques. The white lesions found by MRI in the brains of MS patients are also common to LB. Like syphilis in the 19th century, Lyme disease has been called the great imitator and should be considered in differential diagnosis of rheumatologic, neurologic conditions as well as Chronic Fatigue Syndrome, Fibromyalgia, Somatization and any difficult multi-system illness.
There is not enough research being done on ticks, the pathogens they can carry and their evolution in the human host. Evidence is accumulating that LB may be a congenital disease in some cases. Left untreated it can become neuroborreliosis and there are good indications that it can progress to Alzheimer's disease. LB is probably the most under-diagnosed and under-treated disease that we have in Canada.
The science claimed by the AMMI deserves scrutiny. The CDC should never be left as the 'final word' on anything medical or science related. More independent and pure unfettered science is needed.
The 2001 Klempner study of 129 patients is a case in point. 78 were in a seropositive group and 51 were seronegative with half receiving antibiotic treatment and half a placebo. The study was double-blinded and the results analyzed by patient questionnaires. Before the study was even complete, an expert panel from the Infectious Diseases Society of America (IDSA) published clinical guidelines for treatment of patients with LB. When it came to chronic Lyme, the panel concluded it just did not exist - never mind that the NIH was spending millions on a treatment study of it even as the guidelines went to press.
Publication of the guidelines in November 2000 coincided with the halfway point of the study. As in any drug trial, it is at this point that monitors examine the results and decide if the second half of the study should go on. Given all the limitations no one in the patient community was particularly shocked when the monitor found no benefit to treatment. The study was halted at once. In June 2001 the results were published over the internet to great fanfare by the New England Journal of Medicine. The press release from the United States Institute of Health (NIH) declared "Clinical Alert: Chronic Lyme Disease Symptoms Not Helped by Intensive Antibiotic Treatment," instead of announcing the failure of this one treatment in this limited group of patients, NIH had applied results to all treatments for all patients with chronic symptoms of LB.
Media coverage was intense. "Antibiotics don't cure chronic Lyme disease," announced Time magazine. The New York Times quote of day was from Leonard Sigal: "Lyme disease, although a problem, is not nearly as big a problem as most people think. The bigger epidemic is Lyme anxiety." The patients never expected the NIH to orchestrate such an overwhelming blitz of PR. The Klempner study hardly rates being called level one science yet it is trotted out again and again by the AMMI as one of the evidenced-based, peer-reviewed studies that justify their intransigent dogmatic stand. They ignored the Fallon critique of Klempner's threshold being set too high to detect a treatment effect. Not a big problem? Why then on August 19th, 2013 did the CDC issue a press release indicating that they had been misreporting the actual number of new cases every year by a factor of ten. Instead of 30,000 new cases every year there are likely 300,000 or more.
The dangers of antibiotic use are often mentioned. Many physicians treating Lyme disease use antibiotics or combinations of antibiotics that are well tolerated, have fewer side effects and have a higher degree of safety with the oral route rather than I.V. Patients are advised to take pro-biotics (e.g. acidophilus) supplements at least 4 times a day in order to avoid C-difficile.
Borrelia are pleomorphic like Treponema and can live in biofilm plaques which are 1,000 times more resistant to antibiotic attack than individual organisms. They are very slow to divide taking about 20 hours on average. Many of our antibiotics work only on the dividing cell which means treatment takes much longer than is the case with other infections. Different modalities are being investigated and one of the recent more promising finds is that it might not be what antibiotic but when it is delivered that may make the difference. When attacked by antibiotics 20% of the Borrelia go into a cell wall deficient form ...a type of stasis, until the environment becomes safer for them again. Borrelia do not develop antibiotic resistance. When these bacteria remerge from stasis they are na?ve to the antibiotic and more can be killed off. Perhaps this 5 day on and 5 day off pulsed medication regimen will prove successful.
When evaluating a patient for LB it makes it easier if the patient fills out a questionnaire before they are seen. What, for example is the likelihood that they have been exposed to ticks? Do they have pets? The Canadian Lyme Disease Foundation (CanLyme.com) lists in excess of 70 possible symptoms. Lyme disease is the only one of this constellation of diseases in which the symptoms seem to move around over time and that is diagnostic in itself. It is understandable that most physicians would be reluctant to treat such time-consuming complex cases without additional training. Since treatment is over an extended range of time, even fewer physicians would want to develop the expertise required. This is more a marathon than a sprint with even a simple case taking 6 months to a year to treat. Many patient groups feel this multi-system disorder would best be managed by Internal Medicine since it crosses so many disciplines. At the moment there is no proper teaching of Lyme disease in any of our medical schools and this will have to change in the light of the growing seriousness of this pandemic to the health of the public.
References
1. Canadian Adverse Reaction News Letter, Vol.. 22-issue 4, Oct. 2012
2. "Cure Unknown: Inside the Lyme Epidemic" Revised Edition 2013, Pamela
Weintraub, St. Martin's Press, 456p.
3. "Seronegative Lyme Disease,"Dattwyler et al., N Engl. J. Med., vol. 319 No 22, 1441"
4. "Lyme and Associated Tick-Borne Disease. Global challenges in the context of a public health threat," Christian Perrone, PhD, MD, Front., Cell. Infect. Microbiol., 03 June 2014
5. "Antimicrobial retreatment of Lyme disease in patients with persistent symptoms:' a biostatistical review, Delong A.K., BlosomB., Maloney E.L., abstract Pub Med, Nov 2012
6. Canadian Lyme Disease Foundation http://www.canlyme.com
Conflict of Interest:
None declared
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Diphenhydramine is not the correct treatment for anaphylaxis!
Submit responseChing et al. present a very interesting case of a child with passive transfer of fish and peanut allergy following a platelet tranfusion.
Unfortunately, the case study describes how this child's anaphylaxis was mismanged on two separate occassions. During each of his emergency department visits, the boy received diphenhydramine, an anti-histamine.
It is quite clear that he should have received intramuscular epinphrine both times. It is the only medication that can reliably help with airway obstruction and cardiovascular shock. A delay in administration of epinephrine can be fatal.
Conflict of Interest:
None declared
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Divesting fossil fuel investments by CMA
Submit responseI have significant concerns about the August 24, 2015 news piece article entitled "Doctors Call for Divestment From Fossil Fuels." Dr. Howard has every right to invest HER money as she sees fit but I do not want her to make ME invest MY money as SHE sees fit.
Dr. Howard says in the piece that: "Given all of the information that has been in medical journals about it that's a real failure of communication on the part of our profession." "This year, the Lancet Commission on Health and Climate Change published studies linking climate change and public health."
No. These are not studies. They are opinion pieces. There is no data in the articles.
The article goes on to say: "In the summer of 2014, Howard said she witnessed the effect climate change when Yellowknife was cloaked in heavy smoke from area wildfires and she noted more patients wheezing in her emergency department." " The increasing instances of wildfires in North America can be linked to climate change."
There is no solid evidence, in fact, I believe there is no evidence at all to show that these wildfires are related to Climate Change. I would ask someone to explain and prove how these wildfires were caused by climate change.
The article also says that "According to scientists keeping the world temperature from rising more than two degrees means that more than two- thirds of fossil fuel reserves have to stay in the ground."
There is now evidence that the models that predicted massive Global Warming, including the two degree temperature rise, have overestimated warming so far. Some data now shows that there has been no warming for the last 18 years. It makes no sense to waste trillions of dollars on stopping something that is not happening at anything close to the rate mentioned here. That money could be used for useful things like cutting pollution, health care and bringing people out of poverty.
The doctor also says that "In light of this, divestment, according to Howard and Hancock, is a financially prudent choice."
In fact, the big oil companies have never shunned renewable energy in their mix of business operations, and only recently have pulled back investments in solar and wind. But the reasons for that have less to do with conspiracies to rule the world through a fossil-fuel economy than plain old economics.
http://www.nasdaq.com/article/big-oil-and-renewables-not-so-strange- bedfellows-cm405300#ixzz3jJ97PNuX"
I do not want my investments managed by physicians. Had we followed the advice of these physician investors, we might have invested in something like these: "Green energy programs--which have produced more than 50 bankrupt, or near bankrupt, projects."
http://www.cfact.org/2013/07/17/green-energy-often-a-very-bad- investment/
I have no problem with MD Management's offering a non-fossil fuel option for those members who want it. I do not wish my retirement to be at the mercy of someone else's ideology. You want specific funds for the ethics of vegans and not invest in farming? Should we consider the ethics of specific religions and not invest in companies that are not compliant with a religion? Shall we not invest in companies that don't have enough women or minorities in management positions? What about medical research companies, medical equipment sales, brand name drug companies, generic drug companies, the up and coming marijuana industry. If you as an individual want to invest that way, go for it.
Do what you want with your own investments but keep your opinions out of mine. I hired professionals to manage my money. MD Management has a fiduciary duty to those of us who entrusted them with our investments and savings for our retirements.
Yours truly,
Gerald I. Goldlist, MD
Conflict of Interest:
None declared
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Re: Decisions; A 35-year-old man with a positive Lyme test result from a private laboratory
Submit responseThis fictional practice case scenario needs to have some modicum of realism if it is intended to be useful to inform diagnostic and treatment decisions. The patient, who believes he could have Lyme disease and felt compelled to pay out-of-pocket for more potentially informative testing than is available in Canada, would most likely have an extensive list of multi-systemic symptoms, not just one (i.e. fatigue).(1)
He might have shown his primary care provider a rash one year before, but had been told that it looked like a bruise, ringworm, a "spider" bite or cellulitis. Erythema migrans lesions can be highly variable. Unfortunately, many articles (like this one) that continue to promote the misconception that EM rashes are always of "bull's-eye" form are still being accepted for publication when, in fact, a target shaped lesion is a relatively uncommon presentation (less than 20%). (2, 3)
The patient probably saw many physicians over the year, but likely none would have evaluated the full panoply of his migrating and/or cyclical symptoms, been cognizant of expanding local and global epidemiological risk for Lyme, considered tick-borne diseases in the differential diagnosis, or known what relevant questions to ask.
Patients are very aware that Lyme serology performed in Canada has important limitations to its reliability. (4) Testing in Canada (aside from "European Lyme" IgG WB, available from the NML) is based on antibody reactivity to a single laboratory grown strain of a single species of Borrelia burgdorferi. Research has shown our testing will not reliably identify all of the species and strains of Borrelia a patient might be infected with here or abroad. (5, 6, 7)
Health Canada has advised, "Serologic test results should be used to support a clinical diagnosis of Lyme disease and should not be the primary basis for making diagnostic or treatment decisions."(4) In light of the many limitations to the reliability of Lyme serology and in keeping with the diagnosis of numerous serious diseases and medical conditions that are made based on symptom presentation, physical findings and epidemiological risk without requiring a positive antibody test it seems unreasonable and misguided to insist on positive serology in post-acute stages of Lyme disease.
Improved diagnostic guidance, tools and specialized clinical training are needed to provide physicians with the knowledge, expertise and the confidence to use their own judgement in determining accurate diagnoses and whether empirical treatment would be appropriate for a particular individual.
1. Maloney, EL. The Need for Clinical Judgment in the Diagnosis and Treatment of Lyme Disease. Journal of American Physicians and Surgeons. Volume 14, Number 84-3. Fall 2009. Available from: http://www.jpands.org/vol14no3/maloney.pdf
2. Aucott J, Morrison C, Munoz B, Rowe PC, Schwarzwalder A, West SK. Diagnostic challenges of early Lyme disease: Lessons from a community case series. BMC Infectious Diseases. 2009;9:79. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2698836/
3. Lyme MD poster final 3 - PHPA. Available from: http://phpa.dhmh.maryland.gov/OIDEOR/CZVBD/Shared%20Documents/Lyme_MD_poster_FINAL.pdf
4. Health Canada. Canadian Adverse Reaction Newsletter, Volume 22 - Issue 4 - October 2012. Available from: http://www.hc-sc.gc.ca/dhp-mps/medeff/bulletin/carn- bcei_v22n4-eng.php
5. Wormser GP, Liveris D, et al. Effect of Borrelia burgdorferi Genotype on the Sensitivity of C6 and 2-Tier Testing in North American Patients with Culture-Confirmed Lyme Disease. Clin Infect Dis. 2008; 47 (7): 910-914. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2773679/
6. Ivanova L, Christova I, Neves V, et al. Comprehensive Seroprofiling of Sixteen B. burgdorferi OspC: Implications for Lyme Disease Diagnostics Design. Clinical immunology. 2009;132(3):393-400. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752154/
7. Krause PJ, Fish D, Narasimhan S, and Barbour AG. Borrelia miyamotoi infection in nature and in humans, Clinical Microbiology and Infection. July 2015; Volume 21, Issue 7: 631-639. Available from: http://www.clinicalmicrobiologyandinfection.com/article/S1198- 743X%2815%2900294-3/fulltext
Conflict of Interest:
None declared
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Re: Lyme disease: How reliable are serologic results?
Submit responseA thorough examination of the full text of the Fallon study (1), referenced by Gregson et al, demonstrates that for thirty-seven Lyme patients (all of whom met historical clinical AND laboratory criteria for LD) archived sera from fewer than half of these confirmed patients (37.8%- 48.6%) tested positive at each of all four laboratories using the CDC two- tiered algorithm for ELISA and IgG WB. The Fallon et al study also demonstrated a considerable lack of concordance among the labs; thus, patient sera may test positive at one lab but not another. This would suggest that the answer to the title question is: less reliable than a coin toss.
Using IgG WB, specialty Lab B did, in fact, correctly identify significantly more of the patients as being positive with in-house interpretation criteria than any of the labs using CDC criteria. (70.3%)
Specialty Lab B was also the laboratory that had specificity problems among the healthy controls using their in-house criteria. However, subsequent to the Fallon et al study, that laboratory learned from those problems and undertook a new and larger study (2) which allowed them to evaluate the reactivity issues more thoroughly, test further hypotheses and innovate. As a result of this research, they changed their in-house laboratory interpretation criteria, which should be viewed as a scientifically progressive step that may significantly improve Lyme disease serology sensitivity and specificity.
Health Canada acknowledged that current laboratory diagnostics have important limitations to reliability with the publication of the Canadian Adverse Reaction Newsletter, Volume 22 - Issue 4 - October 2012.(3) Given these limitations, physicians and patients need to understand that Lyme disease always needs to be a clinical diagnosis that should be made by medical practitioners who have both expertise diagnosing tick-borne illnesses and familiarity with the constellation of Lyme presentations.
1. Fallon BA, Pavlicova M, Coffino SW, and Brenner C. A comparison of lyme disease serologic test results from 4 laboratories in patients with persistent symptoms after antibiotic treatment. Clin Infect Dis. Dec 15 2014; 59 (12): 1705-10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25182244
2. Shah JS, Du Cruz I, Narciso W, Lo W and Harris NS. Improved Sensitivity of Lyme disease Western Blots Prepared with a Mixture of Borrelia Burgdorferi Strains 297 and B31. Chronic Dis Int. 2014; 1 (2): 7. Available from: http://austinpublishinggroup.com/chronicdiseases/fulltext/chronicdiseases- v1-id1009.php#
3. Health Canada. Canadian Adverse Reaction Newsletter, Volume 22 - Issue 4 - October 2012. Available from: http://www.hc-sc.gc.ca/dhp- mps/medeff/bulletin/carn-bcei_v22n4-eng.php
Conflict of Interest:
None declared
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Solution for Syria
Submit responseSyria and the whole region should be ruled by an international executive based in the most developed parts of the world to save so much life, wealth and human rights as possible. The birth rate must be efficiently restricted.
Reference
Jargin SV. Demographical Aspects of Environmental Damage and Climate Change. Climate Change, 2015;1(3):158-160
Conflict of Interest:
None declared
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Re:Breast Self-Exam
Submit responseI agree with Young Survival Coalition - Atlanta. What I see in the Baxter's study is that it never looked at the recommendations of the physicians's to women who come to them for check-up of their lumps. We are eight girls in the family, three detected breast lumps through BSE. One of them after seeking medical attention had a hysterectomy because it turned that her condition spread down to her cervix. One waited for 5 years to have it removed since the doctor said it was benign, no mammography was done, the removed tissue was negative of cancer cells. It was removed because of discomfort. The youngest one still have the lump after 10 years of detection, but she changed her diet. All of them were taught how to monitor lumps and changes. They were given health education by the doctors not a prescription of a mammography or biopsy. In my perspective what the research should look into is the current protocol of management of breast lumps when it is detected. Probably, it needs some change.Conflict of Interest:
None declared
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Re:Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care
Submit responseDear Editor,
We thank the authors for their letter, but this was not a population simply defined by tympanometry, being a symptomatic population (see Table 2), with a median of 6 symptoms in the standard care group, and 7 in the autoinflation group (1) - the vast majority with hearing loss. Otitis Media with Effusion (OME) symptom scores improved in the treated group at 3 months, as did the OMQ-14(OME symptom/QoL measure). Otoscopy was used primarily to exclude other ear pathology since the specificity of otoscopy for OME is poor, (2) pneumatic otoscopy is not used reliably in primary care, and is also associated with concealment bias. Tympanometry was performed by trained nurses who used the modified Jerger criteria.(3) Children with very low canal volumes were not classified as B types. The authors' references to their experiences of poor compliance are more than 20 years old, so either different explanations/techniques were used, or perhaps perceptions of parents and children have changed. Our simple pragmatic approach was very acceptable in present day primary care. If self-report overestimated compliance, we will have underestimated the benefit of autoinflation. Studies included in the Cochrane review have mostly estimated compliance as either good or satisfactory. (4) Our aim was to address clinical effectiveness for the majority of children with OME related symptom concerns in the community where the vast majority of children are managed, not those seen in ENT clinics or in need of surgery, and we have shown clearly the benefit of this simple method of non-surgical management.
References:
(1).Maw AR. Presentation and Diagnosis. In Bax M, editor. Glue Ear in Childhood. Clinics in Developmental Medicine No. 135. London: Mac Keith Press; 1995. pp. 47-60.
(2).Jonathan DA. Sonotubometry, its role in childhood glue-ear. Clinical Otolaryngology and Allied Sciences 1989;14:151-4.
(3).Jerger J. Clinical experience with impedance audiometry. Arch Otolaryngol 1970;92:311-24. http://dx.doi.org/10.1001/archotol.1970.04310040005002
(4).Perera R, Glasziou PP, Heneghan CJ, McLellan J, Williamson I. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev 2013;5: CD006285. http://dx.doi.org/10.1002/14651858.cd006285.pub2
Conflict of Interest:
None declared
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All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
