177 e-Letters

  • Robust medical research demands both reproducibility and generalizability to ensure that findings translate into effective clinical practice

    This systematic review and individual patient data meta-analysis aimed to evaluate the safety and efficacy of primaquine in patients with Plasmodium vivax malaria from South Asia. The study's strengths include its comprehensive search strategy, thorough data extraction, and robust statistical analysis. However, several limitations and concerns arise from the study's methodology and results.

    Firstly, the study's generalizability is limited by its focus on South Asia, which may not be representative of other regions where P. vivax malaria is endemic. Additionally, the study only included patients with uncomplicated P. vivax malaria, which may not reflect the more severe cases often seen in clinical practice.

    Secondly, the study's inclusion criteria were quite restrictive, leading to the exclusion of 14 out of 32 identified studies due to lack of primaquine arm or incomplete data. This raises concerns about selection bias and the potential for missing important data.

    Thirdly, the study's definition of "low" and "high" total dose primaquine regimens seems arbitrary and may not be universally accepted. The categorization of daily doses into "low", "intermediate", and "high" also lacks clear justification.

    Fourthly, the study's haematological safety analysis was restricted to patients with ≥30% G6PD activity, which may not reflect the real-world scenario where patients wit...

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  • Re: Comparison of WHO versus national COVID-19 therapeutic guidelines across the world: not exactly a perfect match

    Dear Editor,

    I noticed in Figure 2 of the article, “Comparison of WHO versus national COVID-19 therapeutic guidelines across the world: not exactly a perfect match”, that Taiwan was shown among “countries with no response or no access to their guidelines”. As the main coordinator of Taiwan’s COVID-19 Therapeutic Guideline Expert Committee, I am eager to share with your readers how we developed and revised our national guideline (NG) during January 2020 to December 2023, with the latest version being version 25 (1). Our committee was composed of experts from different fields, including clinicians (infection specialists, pulmonologists, intensivists), infection control specialists, laboratory experts, etc. We diligently reviewed the latest evidence on COVID-19 therapeutics, and revised the guideline timely.

    For example, in version 2 of our NG, published on 2 February 2020, we recommended that lopinavir/ritonavir may be considered for patients with severe pneumonia or acute respiratory distress syndrome based on in vitro study results of other coronaviruses, which was the best evidence available at the beginning of the COVID-19 pandemic. The recommendation was retracted in version 5, released on 26 March 2020, soon after results of a clinical trial published on 18 March 2020 showing this was ineffective. Hydroxychloroquine was also once recommended by our NG and later removed after solid evidence against using this drug for COVID-19 treatment became available (...

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  • Nutri-Score and publication bias: it is time for an independent evaluation of the scientific substantiation of Nutri-Score.

    Dear Editor,

    A commentary paper in your journal by Besancon et al. [1] suggests that industry is opposing the Nutri-Score system and hence preferentially publishes papers that support criticism on that front-of-pack label. It is concluded by Besancon et al. [1] that ‘a study is 21 times more likely to show unfavourable results if the authors have a conflict of interest or the study is funded by the food industry’. The figure of ’21 times’ is suggestive because there are too many unscientific assumptions behind this figure. One assumption is that a study is of poor quality or a biased study if it shows unfavourable results to Nutri-Score and/or if there is a mention of a Conflict of Interest, i.e. sponsored by industry. A second assumption is that studies that are carried out by the developers of Nutri-Score are by definition of good quality and unbiased. Moreover, we found out that Besancon et al. [1] did not conduct a comprehensive search of the literature: they just used the literature list on the website of the developers of Nutri-Score (https://nutriscore.blog/author/logonutriscore/ d.d. August 2023). This list was far from complete, i.e. it did not comprise all peer-reviewed papers about Nutri-Score, especially not the papers that are unfavourable for Nutri-Score. Finally, the analysis by Besancon et al. was limited to the outcome of the studies, without considering the detailed content of the pape...

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  • Further Insights into the Dialogue Between Expecting Mothers and Their Doctors Regarding Use of Herbal Remedies in Pregnancy

    Dear esteemed authors,

    Congratulations on this well-designed study. I carefully read your study with great interest. I decided to write a commentary on your study as it discusses a field I am most passionate about.

    - Introduction:
    The introduction provides a comprehensive background on the use of herbal medicine (HM) during pregnancy, the potential risks, and the importance of effective patient-physician communication. The rationale for conducting this systematic review is well-justified.
    - Methods:
    The search strategy is well-described and comprehensive, covering multiple relevant databases and using appropriate keywords and search terms.
    The eligibility criteria for study inclusion are clearly stated and reasonable.
    The process of study selection, data extraction, and risk of bias assessment is described in detail and appears to be rigorous.
    The methods for data synthesis and statistical analysis, including the use of subgroup analyses and correlation analyses, are appropriate and well-explained.
    - Results:
    The results are presented systematically and clearly, with the use of tables, figures, and forest plots to effectively visualize the findings.
    The findings related to the prevalence of HM use during pregnancy, the rates of disclosure to healthcare providers, and the factors associated with disclosure are insightful and well-supported by the data.
    The subgroup analyses based on geographical regio...

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  • Pragmatism has its place in qualifying the use of 'global health'

    We would like to thank Professor Holst for taking the time to read and respond to our article. Indeed, in developing the piece, we read with great interest Professor Holst’s 2020 article on emergence, hegemonic trends and biomedical reductionism in global health. We acknowledge that global health is a broad and complex field, and ongoing discourse around terminology is welcome and encouraged.

    As Professor Holst himself states, “the predominant Global Health concept reflects the inherited hegemony of the Global North”.(1) With this is mind, we sought in our paper to articulate a practical interpretation of global health that emphasises the critical barriers to universal health coverage and optimal health outcomes. The challenges of access, resource and context limitation are global in nature, and do not relate exclusively to the provision of “humanitarian aid”. We agree with Professor Holst that addressing these issues requires trans-national solutions and multi-sectoral engagement.

    In articulating the ARC-H principle, we acknowledge that we have applied a “clinical-biomedical” frame. This reflects our work as emergency physicians who have borne witness to the direct and indirect consequences of access-, resource- and context-limited healthcare. Our interpretation is pragmatic, and deliberately serves to emphasise the expertise and lived experience of ARC-H populations.

    In no way do we seek to minimise the social, environmental, political and commer...

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  • Global health, humanitarian, and human rights organisations must be taken seriously in discussions to end Israel’s offensive on Gaza

    In a February correspondence to BMJ, Greenland et al opined that an end to violence in Palestine “can only occur when Hamas ends its war to destroy the state of Israel...”.[1] The Israeli offensive, the authors argued, is legitimised by the support of “the governments of the UK, the USA, Germany, France, Italy and other sovereign states”[1] and purported “evidence” contained within predominantly North American news outlets including the New York Times, CNN, and the Washington Post.

    What the article glaringly omits are the evidence-based analyses and unified first-hand accounts of global health, humanitarian, and human rights organisations operating in Gaza – organisations borne in direct response to war atrocities and mandated to alleviate suffering, protect rights, uphold international law, and maintain neutrality, peace, security, and diplomacy. How far we have fallen if the experiences of such organisations are no longer considered valid and worthy of reference, but violence and oppression are legitimised through citing unreliable sources at best, and biased standpoints of political and vested interest at worst. Disappointingly, such citations undermine the high ethical standards of journals like the BMJ. In the interests of respecting evidence and facts, we highlight experiences from global bodies to refute Greenland et al’s baseless claims.

    First, the authors dispute the occupation of Gaza itself, claiming – using a misquoted Wikipedia reference[2] – “t...

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  • Joint authorship and author order

    The authors are to be commended on an important article which makes a compelling point.

    Out of interest, where authors are appropriately credited as joint first and joint last, should their names then be listed alphabetically? In the example of this paper, this would place authors based in more resource-poor countries as the first and last listed authors, and would also seem the more rational ordering if authorship is jointly shared. There is some evidence that the ordering of 'joint first' authors does involve some implicit biasing in terms of gender balance - might this not also be an issue in work published as part of an global partnership? Attributing authorship can be genuinely difficult, but where equivalence is recognised it then seems concerning that the chosen (but not explained) order still places the high-income authors in the traditional positions of distinction.

  • Sacrificing globalism on the altar of decolonisation

    Recently, in BMJ Global Health, Nasir Jafar and colleagues made another attempt to redefine 'global health'. They aim for 'greater clarity and precision' in a pragmatic and more inclusive sense, with the noble objective '‘to offload colonial vestiges present within the field and terminology of ‘global health’.‘ While this goal is undoubtedly right, important and overdue, the argument is alarmingly unconvincing and narrow. In their attempt to redefine, or rather reinterpret, global health, the authors make two important restrictions. Their proposal is based on an understanding of global health that is limited not only to a single country, but also to the field of humanitarian aid. Health emergencies and relief are only part of global health, so reducing the latter to humanitarian aid is absolutely unacceptable. It blatantly neglects both the meaning of "global" as "universal" and the complexity of global health as an explicitly political concept.

    The second, unacceptable limitation is the authors' narrowing of global health to healthcare and healthcare systems. It may be that a clinical-biomedical understanding dominates the theory and practice of global health, but the call for an a posteriori recognition of pragmatic development should not distract from the fact that global health is much more complex, encompassing the social, environmental, political and commercial determination of health, as well as inequalities...

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  • Enhanced infection susceptibility due to chronic starvation in polar bears

    A recently published article addresses the worrysome connections existing between the progressively increasing Arctic Sea ice melting and the chronic starvation experienced by polar bears (Ursus maritimus) (1). Indeed, the progressively declining Arctic Sea ice thickness represents a leading cause of the profound ecological, behavioural, feeding and dietary pattern modifications reported with an increased frequency in this highly threatened apex predator (1).
    Within such an alarming context, the animals' chronic stress deriving from prolonged starvation is an additional matter of concern. Indeed, besides being a powerful and efficient machinery allowing us and all the other living organisms to cope with a huge number of environmental stressors, chronic stress responses are invariably characterized by immunosuppression, originating from enhanced cortisol production (2). Therefore, while increased cortisol levels should be reasonably expected to occur in the blood of polar bears experiencing chronic starvation (1), it should be emphasized they may also become, at the same time, much more susceptible to microbial pathogens impacting their health and conservation status.
    This could be especially true for Toxoplasma gondii, a cosmopolitan and zoonotic protozoan parasite infecting humans and a large number of terrestrial and aquatic mammal species, including polar bears. In this respect, anti-T. gondii antibodies were previously  reported in almost half of the p...

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  • In support of this broader view

    I would like to register my strong support for this viewpoint. I am part of a large group of >200 physicians, researchers, and academics who endorsed and contributed to this article. Unfortunately, as part of a highly disappointing series of editorial decisions, BMJ Global did not allow the authors to publish our names and information as a supplement to this article (which was the original plan). I therefore would like to register a rapid response documenting that I was one of the extremely large group of academics who endorsed this article.