10 e-Letters

  • Some conclusions are not supported by data

    The authors conclude that:

    "Development of robust evidence of the putative effectiveness of the non-mainstream treatments being used should be a priority given that they are being used by carers."

    This reads as a call for studies based on confirmation bias. The purpose of research is to test a hypothesis, not to develop an evidence base to support a belief.

    "... paediatric doctors are increasingly turning to more natural treatments"

    No evidence to support this claim is presented, either in the study data or via references. Longitudinal data were not collected. There is nothing natural about homeopathy, as its claimed mode of action violates laws of physics and chemistry.

  • Time to go back to school: national governments prejudice children's rights

    Crawley E et al, in their excellent editorial (1) stress the harmful effects of school closings and social distances affecting children and adolescents following the COVID-19 pandemic. There are other different reasons that must push governments to conscientious school measures and educational supports as a significant damage to the educational and mental health of children and adolescents.

    First, as all international agencies have highlighted, prolonged closure yields serious consequences for all children and particularly for those already living in difficult circumstances, such as extreme poverty, disability, or violent environments (2,3).
    UNESCO estimates that at least 177 countries have instituted school closures at national level and several other countries have established closings at regional or local level (4). With over 90% of students worldwide (more than 1.5 billion young people) currently out of the educational context, it is clear that the greatest threats from Covid-19 to children and adolescents are to be found in educational loss, poorer nutrition, increased exposure to intrafamiliar violence, rising incidence of mental health disorders and lack of physical activity rather than in the clinical consequences of Covid-19 infection (4-8). Inequality in education and health will increase dramatically as consequences are inevitably greater for vulnerable children due to social, material and educational poverty, disability and chronic diseases, specia...

    Show More
  • Inaccuracy in reporting CEBA part II

    Malik et al. conducted a randomized trial of cognitive-behavioral therapy (CBT) combined with music therapy for adolescents with chronic fatigue (CF) following Epstein-Barr virus infection. (1) Unfortunately, there are several problems with how the findings of this trial are reported.

    First, it appears that the study was rephrased as a feasibility trial when the intervention failed to provide the expected effect sizes. The trial was only powered to detect large effects and both the protocol (2) and statistical analysis (3) plan suggest that the authors were expecting to find large improvements in the intervention group. In their power calculation for the primary outcome (mean number of steps per day) they wrote: “In the present study, the power to detect an increment of 2000 steps/day is at least 80 % (α=0.05). This effect size is rather large (0.8 times the standard deviation); however, as CBT alone is documented to have small to moderate effect size in CFS/ME, only a substantial effect size is of direct clinical interest. Also, the FITNET study suggests that larger treatment effects might be assumed in adolescent CFS/ME patients as compared to adults (Nijhof 2012).” (2) The protocol (2) and trial registration (4) include more than 20 outcome measures suggesting the study aimed to test the efficacy rather than the feasibility of the intervention.

    Second, Malik et al. conclude that “combined CBT and music therapy is feasible and acceptable in adolescent posti...

    Show More
  • Adapting to living with CFS/ME

    The authors' aim to explore the underlying patterns of physical activity among youth with mild to moderate CFS/ME found sub-groups of activity patterns including active light, and non-active as measured by accelerometer. While the authors discuss the relationship between physical activity and symptoms of CFS/ME, the authors do not operationalize the vigorous or increase in physical activity prior to the analysis. Thus it is unclear how to compares the physical activity observed in the study to that found in other studies or with populations where fatigue is a prominent symptom of a chronic disease.

    Additionally, missing from the analysis is a baseline of youth activity to control for any changes that the accelerometer might produce or as a result of participating in the study. The importance of this baseline also establishes if past activity patterns might indicate 'moments' of vigorous activity or increased activity that lead to physical crashes reported by many people living with ME/CFS. Avoiding vigorous activity or becoming anxious about physical activity might also explain the levels of activity discussed in the study. Adding a qualitative protocol to this study might highlight relationships between quantitative variables such as physical activity and anxiety or other variables not previously identified by the researchers.

    Finally, the researchers indicate that consulting a patient advisory group, but do not provide any descriptions o...

    Show More
  • Targeting activity levels in ME/CFS

    Michiel Tack

    Email Address *

    Occupation *
    ME/CFS patient

    Affiliation *
    Independent researcher

    Contrary to what is claimed by Solomon-Moore et al., [1] the study by Van der Werf et al., (reference 17) [2] found little evidence of a boom and bust activity pattern in adult patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The Dutch researchers measured physical activity using actimeters worn for 12 consecutive days. There was no significant difference in day-to-day fluctuations in physical activity between ME/CFS patients and controls. The peak amplitude and peak duration of physical activity were larger in controls than in ME/CFS patients while the latter had longer rest duration after an activity peak. Another actimeter study [3] found no supporting evidence of a more fluctuating activity pattern in patients with ME/CFS compared to controls, during the day, nor during consecutive days. Now, Solomon-Moore et al. report that in children and adolescents with ME/CFS, no fluctuating active or boom-bust physical activity pattern could be identified.

    It would be helpful if the authors could clarify how the actimeter data impacted the treatments in the MAGENTA trial. According to the trial protocol [4], one of the interventions aimed to “convert a boom–bust pattern of activity (lots 1 day and little the next) to a baseline with the same da...

    Show More
  • Are you administering just "maintenance" fluid?

    Graham, Smith

    Email Address * smithgc@cardiff.ac.uk

    Occupation * Consultant Paediatric Nephrologist

    Affiliation * University Hospital of Wales

    This is another article on the potential risks of using hypotonic intravenous solutions and the perceived risk of promoting hyponatraemia. I am concerned that this, as with other publications on the topic, uses the term "maintenance fluids" when the fluid being prescribed is also serving the role of "resuscitation" and/or "replacement". While this study may not have seen any cases of hypernatraemia in patients receiving 0.9% saline, we have. The idea that the prescription of just one type of fluid i.e. an isotonic one, is suitable in all paediatric patients covered by this studies' selection criteria reflects laziness on the part of the doctor.

    For accurate prescribing of intravenous fluid, the doctor should think of three different requirements:
    1. Resuscitation fluid
    2. Replacement fluid
    3. Maintenance fluid

    Resuscitation fluid is administered to correct a deficit in the ECF volume. I wonder if this study tries to eliminate this by excluding children with "urinary osmolarity greater than 100 mOsm/kg and a weight change >2% in the first 24 hours". Unfortunately it is not clear by how much the 48 hour study period of fluid administration overlapped with the first 24 hours of admissi...

    Show More
  • Junior soldiers

    I spend 2 years training junior soldiers. I have to say it was the most rewarding job I had in the army, taking 16 year olds from all parts of Scotland we turned these youths in to proud, responsible, enthusiastic young men. These men and their families would be the first to support the system ! Many of them went on to senior positions in their regiments.
    It is madness to deprive young people of these opportunities based on politically motivated medical mumbo jumbo. With the current youth/knife crime crisis most intelligent folk say kids need some form of structure and opportunity in their lives.

  • Reply to letter from Professor Gorodischer and colleagues on access to health care in Palestine

    We thank Professor Gorodischer and colleagues for their comments on our article on Access for Health Care for children in Palestine.
    We believe that politics and health are inextricably intertwined, and this view is shared by WHO in the Commission on Social Determinants of Health and by many commentators such as Professor David Hunter https://www.bmj.com/content/350/bmj.h1214
    We consider that health is politically determined and this is evident in relation to public health issues such as the role of the tobacco industry in smoking, the role of the food industry in nutrition, and the relevance of pharmaceutical industry funding of politicians in determining health policy in the USA.
    In relation to the connection between the occupation of Palestine and the health of its population, this is not controversial but is a fact, corroborated by WHO, UN, UNRWA, the Lancet and many non-governmental organisations such as Medical Aid to the Palestinians. For example -

    Show More
  • Access to healthcare for children in Palestine

    To the Editor,
    BMJ Open

    We concur with the authors that the health care of Palestinian children is far from desirable, and for many of them, particularly in Gaza, has even tragic consequences.

    However, the article has a clear political agenda, which is openly indicated in its last sentence. The authors chose to ignore the complex geopolitical circumstances in the area and the article is far from presenting an objective description of the situation.
    The authors mention the following providers of medical care for Palestinian children: UNRWA, Non- governmental organizations, Palestinian Red Crescent and the private sector. They fail to mention Israel as a health care provider: although following the 1993 Oslo Accord, responsibilities of health care were transferred from Israel to the Palestinian territory, every year over 160,000 Palestinians from the occupied territories receive medical treatment in Israel 1,2. Prior to the year 2005, when the Palestinian Authority took over the Gaza administration, pediatricians from the Gaza Al-Shifa

    Hospital came to the Soroka University Medical Center Pediatric Department in Beer-Sheva, Israel, for various periods of professional update, and pediatricians from the Israeli hospital periodically joined clinical rounds at the Al-Shifa Hospital Pediatric Department; often mutual friendly professional relations developed among pediatricians of both hospitals.
    We refrain from debating here the authors...

    Show More
  • Post-exertional fatigue is not equivalent to post-exertional malaise

    To the Editor: Dr. Wyller and his research team are to be commended for their efforts to validate the Systemic Exertion Intolerance Disease (SEID) criteria (1). As a co-author of the US National Academy of Medicine (NAM, the new name for the Institute of Medicine) report (2), I encourage testing of it and have written about how, without a diagnostic gold standard test, case definitions could be judged by whether they help clinicians and researchers prevent, understand, treat, or predict the course of a medical condition (3). There are a two concerns I have about this study.

    First, Wyller et al. noted that 39% of their subjects (45 out of 115) qualified for the SEID criteria while 61% did not. What were the most common reasons for why subjects did not qualify for the SEID criteria? Were these primarily qualitative reasons, where the SEID group were more likely to suffer from a particular symptom at all, or a quantitative one, where, for example, both groups experienced the same symptoms but the former experienced them at a higher intensity? Understanding these differences would lend further context to their results and assist in future refinement of any ME/CFS criteria.

    Second, although the authors acknowledge lack of a PEM-specific item in their study, I wish to re-emphasize that post-exertional fatigue is not equivalent to post-exertional malaise. As described in the NAM report, PEM is not only increased fatigue following activity but also involves exa...

    Show More