It remains controversial whether overweight and obesity confer
protection when one becomes afflicted with a chronic disease. The debate
would benefit from a shift in focus from susceptibility to more serious
iterations of a whole range of chronic medical problems, to the obese
sustaining higher acute risks from anaesthetic, pregnancy and post
operative complications. They are more difficult to resuscitate in trauma
and...
It remains controversial whether overweight and obesity confer
protection when one becomes afflicted with a chronic disease. The debate
would benefit from a shift in focus from susceptibility to more serious
iterations of a whole range of chronic medical problems, to the obese
sustaining higher acute risks from anaesthetic, pregnancy and post
operative complications. They are more difficult to resuscitate in trauma
and critical illness. Life-sustaining procedures such as intubation and
central venous access pose an anatomical challenge. Due to their thickset
habitus, even the longest chest drains could fail to reach large clots
pressing on lungs in major trauma. The treat of loss of life and limb with
acute injury and serious illness could be far more effective message than
low grade hazard spread over years to decades.
On another note, society's obsession with physical apperance and
attractiveness remains a fixture. Dieting, weight consciousness, anxiety
about body weight/shape and widespread hostility to obesity are
fundamental themes in contemporary life. There is tension between trying
to control our body weight in the midst of unprecedented access to
unhealthy foods. The impulse to ridicule and publicly monitor the body
shape has its basis in the highly visible markers of overweight
transgressing aesthetic standards and signalling pathology and disease.
Seeing fatness leads to the negative reading of fat bodies.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Adjunct associate professor, School of Public Health and Social Work
O Block, Room O-D610
Victoria Park Road
Kelvin Grove, Brisbane QLD 4059
Queensland University of Technology, Brisbane
Clinical senior lecturer, Division of Anaesthesiology and Critical
Care, University of Queensland Medical School, Brisbane.
Acute Care Programme, Mater Research Institute, The University of
Queensland, and Division of Critical Care and Anaesthesiology, Mater
Health Services, South Brisbane, QLD 4101.
I thank Mr Svoboda and honorary adjunct clinical professor Van Howe
(S&VH) for their Letter [1] responding to our critique [2] of their
article [3] criticizing the 2012 American Academy of Pediatrics (AAP)
infant male circumcision (IMC) policy statement [4]. Their Letter provides
little in the way of material disagreement with our critique [2], in which
we pointed out the extensive factual errors in their article [3]....
I thank Mr Svoboda and honorary adjunct clinical professor Van Howe
(S&VH) for their Letter [1] responding to our critique [2] of their
article [3] criticizing the 2012 American Academy of Pediatrics (AAP)
infant male circumcision (IMC) policy statement [4]. Their Letter provides
little in the way of material disagreement with our critique [2], in which
we pointed out the extensive factual errors in their article [3]. Instead,
their Letter is replete with personal attacks and ad hominems, mostly
directed at me. Our conclusion that, "their arguments against male
circumcision are based on a poor understanding of epidemiology, erroneous
interpretation of the evidence, selective citation of the literature,
statistical manipulation of data, and circular reasoning" thus stands.
Here I respond to S&VH's new points and the personal attacks.
S&VH begin with a quote from a book review in 1999 by a friend of
mine in Sydney, Professor Basil Donovan. He and other senior academic
colleagues in Australia have come a long way in the past 15 years and now
universally congratulate me for being right about IMC all those years ago.
Although the AAP Task Force did not comprise members with an
extensive academic track record on the topic, it did a reasonable job in
developing an evidence-based policy statement on IMC [4]. The same cannot
be said for the policy committees of medical bodies in other countries to
date. In formulating their policy the AAP Task Force did consider all of
the evidence up until early 2010, including that of opponents. For
example, on page e766, column 1, end of paragraph 4, the AAP policy refers
to a publication by Van Howe, stating, "one methodologically poor meta-
analysis found no effect of male circumcision on chancroid" [4]. On page
e761 the policy states, "case reports, case series, ecological studies,
reviews, and opinions were excluded from the review. Although case reports
and case series are important for generating hypotheses, the Task Force,
limited itself to reviewing analytic studies" [4]. Page e761 and Table 3
describe the conventional system used to rate articles for quality of
evidence. The AAP's policy was not, however, prescriptive. While it
concluded that the benefits exceeded the risks, it also recognized that
for some families cultural and religious factors might be more important
than medical considerations. The policy therefore emphasized education,
access and affordability for those families who choose to have their boy
circumcised.
The AAP's response [5] to S&VH's attack on their policy [3] was
polite, calling for, "respectful dialogue" [5]. The fact that the AAP did
not, "engage in the debate" was why we decided to point out the factual
errors in S&VH's article [3]. The AAP did, however, provide a sensible
response [6] to an attack by Europeans who accused the Task Force of
cultural bias [7]. The AAP argued convincingly that it was Europe that was
culturally biased, not the USA, given the wide regional and ethnic
variation in male circumcision (MC) prevalence in the USA [6]. While the
European Letter (by Frisch et al.) was published in Pediatrics, the same
journal as the AAP policy statement appeared, S&VH's critique did not.
Rather than personal attacks it would have been more appropriate for
S&VH's Letter to address the critiques of claims by opponents. Such
criticisms have been published not just by me, but by many different
researchers [2,8-36]. The critics include a "who's who" of prominent
academics in the field of MC. I am not an author of many of the critiques.
S&VH defend criticisms [18] of statistics in a paper Van Howe co-
authored [37]. Further criticisms of the statistics in this and other
articles by opponents have been published since then [38]. But Van Howe's
statistics have been the subject of ongoing criticisms by many workers
over the years. His first meta-analysis, in 1999, that concluded MC did
not protect against heterosexual acquisition of HIV [39], was disputed on
statistical grounds by Moses et al. [8], and by O'Farrell et al. [9].
Moses et al. pointed out that Van Howe's method of simple data pooling
[40] led to a Simpson's Paradox [41] inverting the outcome. Such
confounding is particularly apparent when frequency data are unduly given
causal interpretations [42]. Van Howe's article became an illustrative
example in a textbook [43] and a review [44] of meta-analyses showing how
Simpson's paradox can lead to incorrect results.
This may have prompted Van Howe to use expensive software requiring
fast computers that can calculate "exact" odds ratios (ORs). Doing this
not only made replication by others difficult, their use as input into a
meta-analysis is largely an exercise in futility because meta-analysis is
an approximate method. His use of these rather than adjusted ORs has been
criticized [11]. Others, who criticized him for reporting a meta-
regression OR rather than a crude OR [10], stated they, "were unable to
reproduce" his calculations. Van Howe's adjustments of randomized
controlled trial (RCT) data for "lead time bias" have been refuted
[16,45]. His adjustments of HPV data for, "sampling bias" [46-48] have
also been criticized [10,45,49]. Instead, Tobian et al. suggested their
own particular, "analyses may underestimate the protective effect of male
circumcision" [50] and Auvert et al. had not only considered Van Howe's
accusation of sampling bias [47], but had conducted an experiment to test
for it [51]. Moreover, Van Howe's "correction" would not apply to data
from urethral sampling [51]. The sampling bias issue has now been rendered
invalid by RCT data demonstrating that MC reduces HPV at the urethra,
coronal sulcus, and penile shaft [45,51,52].
Other problems include Van Howe's use of data for a different control
group than appeared in the original studies [46,53,54], thus risking bias.
His adjustments for "publication bias" should also be questioned, as
indeed Van Howe did himself in a meta-analysis [46]. Indeed in response to
criticisms [11] of one meta-analysis [53], Van Howe admitted that, "the
data ... was improperly extracted"[55] and Van Howe published an erratum
[56]. His more recent meta-analyses omitted RCT and other important data
and many studies listed in his Tables were not included in his meta-
analysis [54].
If one reads the numerous critiques of the studies by opponents one
might conclude that the critics of those studies have a better
understanding of appropriate study design, methodology, data analysis and
the field of research than do the opponents.
S&VH have accused me of "abuse" for circulating an extensive peer-
review of a paper by Frisch et al. [57], but seem unaware that once a
paper has been published a reviewer is free to reveal their identity and
provide critical comments to others. My criticisms of that study were
later published [29,38]. Despite this Frisch ignored the criticisms as he
continued his campaign to have IMC banned in Denmark and elsewhere in
Europe. He persists in selectively citing his own flawed research [57] and
that of a Belgian group [58], while failing to cite the scholarly
critiques of the latter studies [27,29], as well as failing to cite RCT
data [59], meta-analyses [60] and a recent extensive rigorous systematic
review [38]. The emotional response by Frisch [61] to the initial critique
of his study [29] was mostly an ad hominem attack on me, so undermining
his reputation. In a radio interview of Frisch on the BBC his study was
subjected to scathing criticisms by Professor Michael King, a University
College London clinician who studies sexual dysfunction [62].
S&VH criticize our article [2] by saying, "no fewer than 31 of the
references are to other publications by Morris and his co-authors" [2]. A
similar criticism was made recently by a reviewer of a manuscript I
submitted to a good journal, leading the Editor to comment, "we do not
mind self-citation (especially since you all have produced much of the
good literature on the topic - that's why we invited you to write this
paper!". My academic publications on MC exceed 60 of my total of 341.
Readers can make up their own mind about the veracity of the information
contained therein.
Our critique [2] did not imply that the Circumcision Foundation of
Australia (CFA) or its policy statement, "operates with the approval of
the Royal Australasian College of Physicians (RACP)" [1]. Rather, we
stated, "Similar to the AAP's policy, a peer-reviewed policy statement was
published in 2012 by fellows of the Royal Australasian College of
Physicians (RACP), and fellows of other medical bodies on behalf of the
Circumcision Foundation of Australia (CFA)" [2]. I did not initiate or
establish the CFA. The CFA's website states, "On 21 Jan 2010 several
leaders in public health policy and medical science, together with other
interested parties, met at the National Centre for HIV Epidemiology &
Clinical Research to form a new organization named the 'Circumcision
Foundation of Australia'" [63]. I was present at that meeting, was asked
to set up and maintain the CFA website, and was first author of the 12-
author peer-reviewed CFA policy statement that was published in 2012 [64].
S&VH fail to point out that the RACP's policy [65], placed on the
RACP's website in 2010, was the subject of a withering critique published
in an official journal of the RACP after peer-review [31]. Most of the
authors of the critique were the same individuals who co-authored the
CFA's IMC policy [64]. These included Fellows of the RACP and of other
Colleges and medical bodies [63].
I would also like to correct S&VH's understandable assertions about
my involvement with the RACP's policy development. S&VH's misunderstanding
stems from obfuscatory statements made by David Forbes, a paediatric
gastroenterologist who chaired the RACP's IMC policy writing group. I was
in fact engaged by a member of that committee to critically evaluate
successive drafts of the policy as it developed. That prominent health
policy expert was seriously concerned at the lack of due process and
resistance of several on the committee to an evidence-based approach. At a
teleconference held by the committee on 30 Jan 2009 the only item on the
agenda was my most recent detailed critique of their policy draft. Members
of the committee were then allocated different subject areas to correct in
accordance with my advice. Despite this, the policy released 1.5 years
later remained quite flawed. Because of the strong disagreement between
committee members about the policy's contents, their names did not appear.
In contrast, the heavily criticized [26] 2004 RACP policy listed the
committee members' names.
David Forbes came under fire from within the RACP in the lead-up to
release of the policy. This related to his alleged disclosure to The Age
newspaper that the new RACP policy would advise against IMC [66] a year
before it was completed and approved by the RACP. He also caused an
unapproved summary of the RACP policy to be posted on the RACP website.
The uproar that followed led to the removal of that posting. Considerable
disagreement exists within the RACP over its IMC policy and other matters.
S&VH refer to a statement I made in a television interview in 2009.
That interview was prerecorded and selected segments were taken out of
context, as is common practice in the television industry. For a better
appreciation of my position on IMC I suggest that the reader view an
extended interview that appeared online in 2013 in conjunction with an
episode of "60 Minutes" I appeared in [67].
While S&VH and the outlier publications they cite disagree, the
balance of evidence shows that the neonatal period is the simplest,
safest, cheapest and most convenient time of life for IMC, since it
maximizes benefits, minimizes risks and gives the best cosmetic outcome
[4,32,68-70]. Delay will mean barriers that reduce the likelihood of the
procedure occurring, even if the boy or man wishes to be circumcised.
S&VH seem unable to comprehend that ethical and legal arguments in
support of IMC are stronger and more logical than the arguments of
opponents. This should be apparent to most who have read the articles
published in J Med Ethics in 2013 and in other journals since [28,71,72].
Authors worldwide have made the logical comparison of IMC and
childhood vaccination [73-75]. The ethics of each are comparable [64].
S&VH finish with Victorian wisdom. The medical, if not the ethical,
advice they quote remains valid today, even though the science and
benefits are now much more extensive and thoroughly documented.
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TO THE EDITOR: Unexpected critical illness and the possibility of
death for which loved ones and relatives are unprepared leads to upheaval
and is destabilizing. In time-constrained settings where patients and
their families have not had end-of-life discussions about the use of
aggressive treatments, doctors face difficulties with overwhelmed and
unprepared patients and families. For these distressed families, it is
dif...
TO THE EDITOR: Unexpected critical illness and the possibility of
death for which loved ones and relatives are unprepared leads to upheaval
and is destabilizing. In time-constrained settings where patients and
their families have not had end-of-life discussions about the use of
aggressive treatments, doctors face difficulties with overwhelmed and
unprepared patients and families. For these distressed families, it is
difficult to raise the option of limited treatment in the first instance.
After acquiescing to a decision against full resuscitation they may feel
like their loved ones have been short-changed.
Partners and families should be told honestly about the prospects of
meaningful recovery even with maximal treatment. Life and organ support
therapies involve invasive painful procedures, are futile and often
require mind-fogging sedation to be tolerated. A calm rendition of
realistic chances does not equate to paternalism or coercion towards a
palliative treatment trajectory. We need to arrive at a decision together
-- one that is in the patient's best interest as far as is possible --
moderated by humanity, dignity, beneficence and non-malfeasance.
There is no doubt that the ethical, moral and legal quandaries of
whether to withdraw ventilator- and organ support are stressful for,
indeed provoke strong emotions in, families and critical care staff.
Ongoing physiological support as decisions on treatment withdrawal are
being deliberated in courts of law necessarily delay the availability of
scarce intensive care beds to other seriously ill or injured patients with
far better prospects of meaningful recovery. These patients cannot afford
to wait for all-round resolution between families, clinicians and courts.
Surely the high cost of intensive care and the diversion of hundreds of
thousands of dollars from other health care programs bears serious thought
even in times of immense crisis. The health system cannot afford the
thousands of dollars spent each day in the support of a patient for whom
non-meaningful survival, futility and much delayed death is the eventual
outcome. In the unlikely event that one is abel to be weaned off the
ventilator, the patient is still condemned to full nursing care for the
rest of her natural life.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Clinical senior lecturer, Division of Anaesthesiology and Critical
Care, University of Queensland Medical School, Brisbane.
Acute Care Programme, Mater Research Institute, The University of
Queensland, and Division of Critical Care and Anaesthesiology, Mater
Health Services, South Brisbane, QLD 4101.
Schuklenk and van der Vathorst's feature paper articulates powerful
and persuasive arguments to the effect that denying patients with
treatment-resistant depression (TRD) assistance in dying results in
unnecessary suffering and amounts to unfair discrimination against TRD
patients.
Beyond TRD, the same arguments can readily (and in my view
appropriately) be used to support assisted dying...
Schuklenk and van der Vathorst's feature paper articulates powerful
and persuasive arguments to the effect that denying patients with
treatment-resistant depression (TRD) assistance in dying results in
unnecessary suffering and amounts to unfair discrimination against TRD
patients.
Beyond TRD, the same arguments can readily (and in my view
appropriately) be used to support assisted dying more generally, wherever
intractable severe mental distress pertains. This point is also made by
psychiatrist Colin Brewer in his letter in response to the paper [1].
In establishing the case that patients with depression should not
necessarily be considered incompetent, Schuklenk and van der Vathorst's
paper contains the assumption that mental competence is a prerequisite for
access to assisted dying. While most prochoice ethicists take this
position to be axiomatically correct, I suggest that an insistence on
competence - at least as it is usually conceived in medicine - may lead to
unfair discrimination and unnecessary suffering amongst patients suffering
from a particular class of psychiatric disorder, namely those deemed to be
'psychotic'.
As Schuklenk and van der Vathorst describe, even the most prochoice
jurisdictions stipulate mental competence as a prerequisite for assisted
dying. So in the Netherlands, while patients suffering from TRD can obtain
assistance in dying, those with psychotic depression do not qualify,
because treatment decisions by these patients are considered to be often
'not arrived at competently and should be overridden/ignored'. The
fundamental assumption here - and it is a commonplace notion in medical
ethics - is that psychosis equates with mental incompetence. Presumably,
the basis for this position is that psychosis entails disordered or
delusional modes of thought.
TRD can be very severe, as is made very clear by Schuklenk and van
der Vathorst's paper; however, various forms of intractable psychosis can
be at least as -and in some cases possibly even more- difficult to endure.
Psychotic depression, as above, might be one such case; treatment-
resistant severe schizophrenia would also appear to be an extremely
difficult to endure form of psychosis, entailing great suffering - indeed
many of those affected end up committing suicide. While such patients (by
definition) suffer from disordered or delusional thinking, it is not clear
that the desire to end their lives should be deemed irrational.
As with TRD, denial of assisted dying to patients enduring
intractable psychosis is responsible for a great deal of unnecessary
suffering and amounts to unfair discrimination. I suggest that the
assumption 'psychotic = incompetent' should no longer be accepted
axiomatically. Prochoice medical ethicists ought to explore principled
ways by which our conceptions of 'competence' may be refined such as to
permit fair access to assisted dying for those afflicted by intractable
psychotic disorders.
REFERENCES.
1. Brewer, C. Depression is not the only treatment-resistant psychiatric
condition. eLetter, Journal of Medical Ethics, 2 June 2015.
Getting your message across to a patient and their family is
difficult and fraught with misunderstanding. Aside from not having enough
time and patience to explain complex diagnoses and sophisticated treatment
plans as well as ensuring that understanding has occurred, English may not
be the patient's first language.
As a hospital doctor, even when using non-technical terms, I wonder
whether a family member or a p...
Getting your message across to a patient and their family is
difficult and fraught with misunderstanding. Aside from not having enough
time and patience to explain complex diagnoses and sophisticated treatment
plans as well as ensuring that understanding has occurred, English may not
be the patient's first language.
As a hospital doctor, even when using non-technical terms, I wonder
whether a family member or a professional interpreter is capably relaying
acute concerns and nuances of complicated discussions to patients from a
non-English speaking background. The medical team cannot be sure that
questions posed by a patient in return are being faithfully rendered.
As communication is an iterative and interactive process, far more is
"lost in translation" in health care encounters when the several spoken
languages are necessary. Body language can be misinterpreted, with cross-
cultural diversity in health-seeking behavior and beliefs pose further
obstacles to effective communication.
There is no doubt that the ethical, moral and legal quandaries of
whether to withdraw ventilator-support from a child and pregnant adult
clearly dependent on machine-assisted breathing are stressful for, indeed
provoke strong emotions in, families and critical care staff.
Ongoing physiological support as decisions on treatment withdrawal
are being deliberated in courts of law necessarily delay the availability
of scarce intensive care beds to other seriously ill or injured patients
with far better prospects of meaningful recovery. These patients cannot
afford to wait for all-round resolution between families, clinicians and
courts. Surely the high cost of intensive care and the diversion of
hundreds of thousands of dollars from other health care programs bears
serious thought even in times of immense crisis. The health system cannot
afford the thousands of dollars spent each day in the support of a brain-
stem damaged person for whom futility is the eventual outcome. In the
unlikely event that one is weaned off the ventilator, the patient is still
condemned to full nursing care for the rest of her natural life.
I recently cared for an elderly man who had sustained a large brain
hematoma. The son, who had cared for an ailing father for years, stroked
his shock of white hair as he declined neurosurgical treatment on his
father's behalf. As he tearfully looked upon the face of his
uncomprehending father, the son was unwavering in his refusal. He believed
that the great man his father had once been was no longer there. We agreed
that surgery was not going to change that and they went home.
A truthful rendition of diagnosis, treatment and prognosis, as well
as ensuring that the family has understood, were necessary for my
patient's son to confidently make a decision aligned to his father's
wellbeing and priorities. My job was easier without the self-imposed
burden of trying to dictate treatment trajectory. I was satisfied that I
had not, by deception or persuasion, imposed what I believed to be in the
best interest of the patient. Doctors are human after all, with even our
most well-intentioned recommendations susceptible to the the beliefs and
values we hold dear.
I am currently in an ongoing discussion on Richard Dawkins' forum
with a young man who claims to be in an administrative position in an NHS
clinic in London where male circumcisions are performed. He took it upon
himself to quote anonymously some of the referral letters from GPs that it
was his job to process. I suspect his aim was to try to legitimise the
circumcision referrals that he deals with....
I am currently in an ongoing discussion on Richard Dawkins' forum
with a young man who claims to be in an administrative position in an NHS
clinic in London where male circumcisions are performed. He took it upon
himself to quote anonymously some of the referral letters from GPs that it
was his job to process. I suspect his aim was to try to legitimise the
circumcision referrals that he deals with. Instead, it aroused a couple of
gasps of disbelief from me.
His posting can be found here:
http://richarddawkins.net/forum/viewtopic.php?f=1&t=44534&p=1661121#p1659369
And these are the excerpts that particularly made my jaw drop:
"Thank you for referring this eight year old young boy with the
history of inability to retract the prepuce since birth. He has been okay
with it for a while, but quite recently he has been troubled with
recurrent infections and you have kindly treated him with doses of
antibiotics. There are no other medical problems.
On examination, he has got evidence of tight phimosis.
We discussed about the various management options for phimosis at
this age and finally we agreed upon on doing the circumcision. After
having explained the risk involved in the procedure, I have placed him on
the waiting list for GA circumcision as a day case. We hope to see him
shortly."
The use of language here is certainly interesting. If we are to
believe that this excerpt is legit, and not fabricated by this person -
would it appear that there are some GPs on the NHS who are not aware of
the fact that the foreskin is usually not only completely non-retractile
at birth, but also FUSED to the glans? An anatomical fact that has been
known unequivocally since Douglas Gairdner published The Fate of the
Foreskin in late 1949. Almost 60 years ago. Are there some GPs who are
lacking this basic knowledge about human male physiology?
Then of course there is the mention of "phimosis at this age". That's
right, phimosis that apparently needs treating at eight years old. Again,
would it appear that some GPs are still ignorant that the prepuces of
males (and females for that matter) have no set date for becoming
retractile - that some aren't able to fully retract until puberty - and
that it poses absolutely no problem to the owner of the penis pre-puberty?
And I can't but have an overwhelming suspicion that forcible attempts
at retraction are the root cause of the reported recent spate of
infections. Are some GPs genuinely ignorant about the consequences of
forcible retraction?
Another case of referred childhood circumcision for "phimosis":
"This young boy is complaining of tight foreskin. He is not able to
retract it backwards and he never complains of any infection or lower
urinary tract symptoms.
On examination, the foreskin is tight and when retracted back it is
quite painful. I am going to arrange for him an appointment at our Day
Stay Unit to have circumcision, something he agreed on. We will keep you
updated with the outcome."
A boy with no "problems" besides the fact that his foreskin won't go
back. The GP actually tells us he forcibly retracted the foreskin in the
letter, and considers it news to the reader that this is in fact painful.
By the sounds of things, from the fact that he did the complaining
himself, and the circumcision was apparently discussed with him and not
his guardian - I suspect this may be more a case of a self-conscious and
worried young teen than a younger child.
There is no trace of conservative treatments being offered to the boy
- such as topical steroids and gentle stretching - as have been proven to
resolve phimosis in the vast majority of cases, and may well be
appropriate for the boy's age-group. There isn't even a hint that the
doctor discussed with him that the phimosis would likely resolve itself by
the time he reached 18.
Are some GPs still locked into the mindframe that complete amputation
of the prepuce is the standard/only/best treatment for phimosis? And what
about other issues like BXO and frenulum breve? How many GPs are aware
that there are conservative and effective treatments for these issues that
don't immediately resort to cutting a sizeable piece of densely innervated
flesh from the genitals? Do these same GPs treat female genitals with the
same flippancy, I wonder?
In light of this ignorance - I would like to offer these resources
that may be of use to ANY readers (lay or professional) to read, digest,
and come to their own conclusions:
A brief article explaining the care of the intact penis, covering the
varying ages of full retraction and why forcible retraction should not
occur: http://www.cirp.org/library/hygiene/
The definition of phimosis and the conservative treatment thereof:
http://www.cirp.org/library/treatment/phimosis/
The conservative treatment of BXO:
http://www.cirp.org/library/treatment/BXO/
Unfortunately I cannot find anything particularly on frenulum breve,
except for a couple of news articles discussing frenuloplasty - which is
one option that at least doesn't cut it ALL off. Does anyone know if
gentle stretching can resolve frenulum breve?
I'd appreciate any thoughts from anyone in the medical circle on this
matter.
To the Editor:
The rights to unrestrained free speech in Australia, including the
abolition of the ban on hate speech in the Racial Discrimination Act that
makes it it unlawful to "offend, insult, humiliate or intimidate" a person
or group on the basis of their "race, colour or national or ethnic
origin," could incite race based abuse.
Racial discrimination and vilification remains a prescient worry for
the rece...
To the Editor:
The rights to unrestrained free speech in Australia, including the
abolition of the ban on hate speech in the Racial Discrimination Act that
makes it it unlawful to "offend, insult, humiliate or intimidate" a person
or group on the basis of their "race, colour or national or ethnic
origin," could incite race based abuse.
Racial discrimination and vilification remains a prescient worry for
the recently arrived, with children at higher risk of its long-term
adverse effects. As a child growing up in 1980s Australia, I was daily
branded ''ching chong Chinaman''. As an intern in the early 1990's, I
looked after the child of a fellow student who had repeatedly hurled
racial abuse and spat at me as I left for home from school on the bus.
During the week of typhoon Haiyan in late 2013, a man mimicked paddling a
kayak to a Filipino colleague while heckling him to ''row back to where
you came from''. A would-be parliamentarian declared that asylum seekers
were clogging up traffic in western Sydney in the lead up to our most
recent Federal Elections (2013).
None of these personal or very public instances of race-based
vilification were taken seriously enough to court on the basis of injury
to reputation and defamation. The effort and expense required to
instigate and follow through legal proceedings compels most non-majority
non-white Australians to take such insults and threats on the chin. This
aids and abets strong electoral support for Australia's already curtailed
foreign aid to be redirected from Indonesia if it did not allow boats to
be turned away from Australian shores. The inhumane treatment of asylum
seekers remains the biggest elephant in the room, racial prejudice
implemented in a systematic rollout.
How is an immigrant child to deal with unbridled permission to
express hateful abuse? Would its vehemence not be seared into his soul,
just as the vilification 30 years ago at a bus stop remains fresh and
alive in my memory? I am all for free speech, but racially motivated abuse
is threatening and hurtful to the progress of hardworking minorities who
just want to make a go of it in a new country.
I'm sure you are aware of a simple and inexpensive test for heart failure
and pulmonary patients called a six minute walk test. It has many useful
outcomes (e.g. maximum oxygen uptake and possibility of a fairly certain prediction of
mortality in 18 months if the distance walked is less than 300m).
Clearly, over a period, periodic tests show if a patient's
exercise capacity is falling (- 45m) and at least provide some war...
I'm sure you are aware of a simple and inexpensive test for heart failure
and pulmonary patients called a six minute walk test. It has many useful
outcomes (e.g. maximum oxygen uptake and possibility of a fairly certain prediction of
mortality in 18 months if the distance walked is less than 300m).
Clearly, over a period, periodic tests show if a patient's
exercise capacity is falling (- 45m) and at least provide some warning.
Unfortunately, because the patient has access to this information, this allows her to
question her care plan. It is my belief that this situation is seen as a challenge to doctors.
I would appreciate your comments.
Bob Ratcliffe
To the Editor:
It is crucial that hospital staff have ready access to background health
care information about patients who come into their care -- including end-
of-life care preferences -- that allow better decisions to be made.
However, it is important to incorporate the reality that chronically ill
and debilitated patients can at best, only achieve a return to the level
of health or function they had before they becam...
To the Editor:
It is crucial that hospital staff have ready access to background health
care information about patients who come into their care -- including end-
of-life care preferences -- that allow better decisions to be made.
However, it is important to incorporate the reality that chronically ill
and debilitated patients can at best, only achieve a return to the level
of health or function they had before they became really sick. If they
were previously housebound with significant cognitive impairment, I would
be reluctant to start aggressive treatment and then have to deal with the
difficult decision of whether to continue. To do everything for a non-
communicating bed-ridden patient confers legal protection to the treating
team but does the patient fearful of meeting his maker a gross disservice.
Such measures prolong physiological viability at the expense of meaningful
life.
Unlike the inhumanely excessive and overly aggressive treatment
demanded by desperate patients, and complied with by the ICU, there is
often all-round agreement that symptom alleviation, with a focus on pain
reduction, maximising physical comfort and support of the psychological
well-being of both patient and family, is the clinically rational and
humane course to pursue. Before the acute worsening, and in consultation
with their usual treating physician, partners, children and families will
have had to opportunity to discuss and contemplate at length a fundamental
shift of objective to comfort care, preservation of dignity and symptom
palliation.
There is usually time to come to a realization that premorbid or
disease-related quality of life is poor and more aggressive treatment
would be futile. Most of us believe that dying at an old and infirm age
is not something to be raged against or resisted at all cost. For all of
us and every day, life dies at a varied pace. Some race into the abyss of
oblivion and the healthy are inching towards the precipice. Alastair Reid
yields a truthful rebuttal to Dylan Thomas' "Do not go gentle into that
good night." "Curiosity", alluding to a cat's nine lives and a dog's
contentment with its allocated years, is an enjoinder to life as the
prelude to death.
"...to tell the truth; and what cats have to tell
on each return from hell
is this: that dying is what the living do,
that dying is what the loving do,
and that dead dogs are those who never know
that dying is what, to live, each has to do."
We need to bear in mind Kafka's "The meaning of life is that it
stops." The question arises of health resources wasted in futile clinical
care being made available elsewhere, and the substantial opportunity costs
entailed in expensively futile critical care.
The algorithm for equitable distribution of expensive health care
should include probability of meaningful survival, quality adjusted life
years of remaining alive from medical treatment, and the loss of scarce
critical care beds to a competing patient with better prognosis.
I read with interest the article by Luty et al. (1) about the
retrospective survey they conducted to determine whether medical specialty
journals were more likely to publish the research of their own editorial
board members or the research of editorial board members of rival
journals. I was surprised about the high degree (i.e., almost three times
more likely) to which these cases occur.
I read with interest the article by Luty et al. (1) about the
retrospective survey they conducted to determine whether medical specialty
journals were more likely to publish the research of their own editorial
board members or the research of editorial board members of rival
journals. I was surprised about the high degree (i.e., almost three times
more likely) to which these cases occur.
Typically, the reviewer evaluates the merit and acceptability of a
submitted manuscript, but the final decision is made by the editor.
Macrina (2) pointed out that "Reviewers [and editors] must be comfortable
with the job of impartially reviewing the work. Their review of the paper
must not constitute a conflict of interest, real or perceived [by
others]." I believe that editorial board members who want to publish in
their own journals should be required to disclose in their manuscripts
this conflict of interest, since all other authors are always required to
do so, be it financial or other substantive conflict of interest. Bosetti
and Toscano (3) suggested in a recent article a standardized and written
code of ethics which governs all stakeholders (authors, editors, members
of the editorial board and reviewers) in the peer review process, which
includes a mandated disclosure of real or perceived conflicts of interest.
Reyes (4) emphasized that "honesty and good faith in all the actors
involved in the process of biomedical publications remain the cornerstone
of scientific good behavior." I believe that if this relationship breaks
down, publications become nothing more than papers manipulated during the
review process. The ultimate outcome is that science will be distorted.
I agree with Luty et al. (1) that there is most likely not a single
factor attributable to this phenomenon of publication bias and
discrimination. In my opinion, more research should be conducted in this
area because of its importance to science and the many stakeholders
involved, last but not least, the reader of scientific articles.
REFERENCES
1. Luty J, Arokiadass SMR, Easow JM, Anapreddy JR. Preferential
publication of editorial board members in medical specialty journals. J
Med Ethics 2009;35:200-2.
2. Macrina FL. Scientific integrity: Text and cases in responsible
conduct of research. Washington, DC: American Society for Microbiology
Press, 2005.
3. Bosetti F, Toscano CD. Is it time to standardize ethics guiding
the peer review process? Lipids 2008;43:107-8.
4. Reyes H. Honesty and good faith: Two cornerstones in the ethics of
biomedical publications. Rev Med Chile 2007;135:415-8.
It remains controversial whether overweight and obesity confer protection when one becomes afflicted with a chronic disease. The debate would benefit from a shift in focus from susceptibility to more serious iterations of a whole range of chronic medical problems, to the obese sustaining higher acute risks from anaesthetic, pregnancy and post operative complications. They are more difficult to resuscitate in trauma and...
I thank Mr Svoboda and honorary adjunct clinical professor Van Howe (S&VH) for their Letter [1] responding to our critique [2] of their article [3] criticizing the 2012 American Academy of Pediatrics (AAP) infant male circumcision (IMC) policy statement [4]. Their Letter provides little in the way of material disagreement with our critique [2], in which we pointed out the extensive factual errors in their article [3]....
TO THE EDITOR: Unexpected critical illness and the possibility of death for which loved ones and relatives are unprepared leads to upheaval and is destabilizing. In time-constrained settings where patients and their families have not had end-of-life discussions about the use of aggressive treatments, doctors face difficulties with overwhelmed and unprepared patients and families. For these distressed families, it is dif...
Dear Editor.
Schuklenk and van der Vathorst's feature paper articulates powerful and persuasive arguments to the effect that denying patients with treatment-resistant depression (TRD) assistance in dying results in unnecessary suffering and amounts to unfair discrimination against TRD patients.
Beyond TRD, the same arguments can readily (and in my view appropriately) be used to support assisted dying...
Getting your message across to a patient and their family is difficult and fraught with misunderstanding. Aside from not having enough time and patience to explain complex diagnoses and sophisticated treatment plans as well as ensuring that understanding has occurred, English may not be the patient's first language.
As a hospital doctor, even when using non-technical terms, I wonder whether a family member or a p...
Dear editor,
I am currently in an ongoing discussion on Richard Dawkins' forum with a young man who claims to be in an administrative position in an NHS clinic in London where male circumcisions are performed. He took it upon himself to quote anonymously some of the referral letters from GPs that it was his job to process. I suspect his aim was to try to legitimise the circumcision referrals that he deals with....
To the Editor: The rights to unrestrained free speech in Australia, including the abolition of the ban on hate speech in the Racial Discrimination Act that makes it it unlawful to "offend, insult, humiliate or intimidate" a person or group on the basis of their "race, colour or national or ethnic origin," could incite race based abuse.
Racial discrimination and vilification remains a prescient worry for the rece...
I'm sure you are aware of a simple and inexpensive test for heart failure and pulmonary patients called a six minute walk test. It has many useful outcomes (e.g. maximum oxygen uptake and possibility of a fairly certain prediction of mortality in 18 months if the distance walked is less than 300m). Clearly, over a period, periodic tests show if a patient's exercise capacity is falling (- 45m) and at least provide some war...
To the Editor: It is crucial that hospital staff have ready access to background health care information about patients who come into their care -- including end- of-life care preferences -- that allow better decisions to be made. However, it is important to incorporate the reality that chronically ill and debilitated patients can at best, only achieve a return to the level of health or function they had before they becam...
Dear Editor,
I read with interest the article by Luty et al. (1) about the retrospective survey they conducted to determine whether medical specialty journals were more likely to publish the research of their own editorial board members or the research of editorial board members of rival journals. I was surprised about the high degree (i.e., almost three times more likely) to which these cases occur.
Typic...
Pages