Dear Editor
Sokol raises an interesting question about what single intervention could prevent an ethical lapse. He settles on phoning a friend. That is ask a colleague or confidant. Sokol himself describes the cases he has in mind: sex with patients, bulling, lying, invasions of privacy, defrauding the NHS and violent crime. I do hope that Sokol's one-to-one sessions go beyond suggesting to these professionals that check with a colleague before having sex with a patient, being violent or committing fraud.
This is not to overlook Sokol's insight for the more everyday ethical problems clinicals face in their work. Asking for advice is indeed a sensible way to help avoid making mistakes and familiar from the questions clinicians pose each other each day. I do think Sokol needs to go back a step however. A fundamental issue, and one that should concern all doctors, is identifying that the problem at hand is ethical in nature. To phone a friend, you need to know that question you are asking, or the problem one is facing, is an ethical one. Too often issues that in reality are ethical at their root are tried to be resolved as 'clinical' or some other area of relevance to the clinician. Sometimes there is a belief that if we just had such and such a piece of evidence then a situation would be resolved but the mistake lies in seeing a problem as something other than what it is. There is a need then to develop one's 'ethical antennae' to detect such problems in the first place, then one can go on to phone a friend.
If I could offer one single intervention, it would be getting clear on the nature of the problem and in particular identifying ethical issues as ethical ones. After this asking for advice may well be useful. But if you can't see the problem for what it is, it is going to be challenging to make progress on it.
Competing interests: No competing interests
Re: Colchicine in patients with acute ischaemic stroke or transient ischaemic attack (CHANCE-3): multicentre, double blind, randomised, placebo controlled trial
Dear Editor
I am writing this in response to the recently published study evaluating the efficacy and safety of colchicine versus placebo in reducing the risk of subsequent stroke after high-risk non-cardioembolic ischemic stroke or transient ischemic attack (TIA) within the first three months of symptom onset (CHANCE-3). This multicenter, double-blinded, randomized, placebo-controlled trial offers important insights into potential interventions for stroke prevention.
The trial was conducted across 244 hospitals in China, included 8,343 patients aged 40 years or older with minor-to-moderate ischemic stroke or TIA and elevated high-sensitivity C-reactive protein (≥2 mg/L). The primary efficacy outcome was the incidence of any new stroke within 90 days, and the primary safety outcome was the occurrence of any serious adverse events.
Certain aspects of the study that were particularly commendable are that
-The study had a substantial number of participants (8,343), across 244 hospitals providing robust data increasing the reliability of findings.
-The study being randomized, double blinded limits the bias ensuring credibility to the study.
-Administering colchicine within 24 hours of symptom onset aligns with the critical window for stroke treatment, potentially maximizing the intervention's efficacy.
-Also analyzing the data on an intention-to-treat basis strengthens the validity of the findings by considering all randomized patients, regardless of adherence to the treatment protocol.
But I would also like to take this opportunity to address certain limitations of the study
-The 90-day follow-up is too short a period to capture long-term outcomes and the full impact of colchicine.
-The inclusion criterion of high-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L is focusing only on a subset with elevated inflammatory markers, limiting the generalizability of study.
-The study took only a fixed dose of colchicine (0.5 mg twice daily for the first three days, then 0.5 mg daily),overlooking the effects of different dosing regimens.
-Focusing the study exclusively in China limits the applicability to populations with different genetic, environmental, and healthcare system factors.
-And the study does not detail the measures taken to monitor patient adherence to the medication regimen potentially influencing the outcomes.
In conclusion, while the trial did not demonstrate a significant reduction in stroke risk with colchicine, it does provide valuable data on the safety and efficacy of this anti-inflammatory agent in a high-risk population. So addressing these limitations in future research could further give additional insights to the potential role of colchicine in stroke prevention.
Thank you for considering the feedback
Sincerely,
Nandakumar Thiruvoipati MD
Competing interests: No competing interests