Whilst one must of course take into account the mortality figures
whilst treating multi-drug resistant tuberculosis,
there may be other aspects that need to be studied.
The collegues would to well perhaps to address some part of their research
to the mortality of those patients who had been prescribed for a protected
period antituberculous chemotherapy: (this can be for up to two years),
and who have been m...
Whilst one must of course take into account the mortality figures
whilst treating multi-drug resistant tuberculosis,
there may be other aspects that need to be studied.
The collegues would to well perhaps to address some part of their research
to the mortality of those patients who had been prescribed for a protected
period antituberculous chemotherapy: (this can be for up to two years),
and who have been misdiagnosed. There are understandable reasons for the
policy of treating asap. But everyone should be aware of the possibility
of unnecessarily rushing to treat.
The letter from Dr Eltzschig [1] refers to their paper showing that
surgical embolectomy remains an option in severe pulmonary embolism.
Firstly, this required "a multidisciplinary evaluation team with a
widespread reputation for 24-hour availability, 7 days per week" (and over
half of their patients had surgery during the weekend); there must be very
few centres in the world who can offer such a service,...
The letter from Dr Eltzschig [1] refers to their paper showing that
surgical embolectomy remains an option in severe pulmonary embolism.
Firstly, this required "a multidisciplinary evaluation team with a
widespread reputation for 24-hour availability, 7 days per week" (and over
half of their patients had surgery during the weekend); there must be very
few centres in the world who can offer such a service, and few patients
would be able to reach them in time.
Secondly, they acknowledge that their
improved mortality was almost certainly due to including many patients
with submassive PE, a group in whom it is not even universally agreed that
thrombolysis is superior to heparin.
Thirdly, an alternative to
thrombolysis that could be more widely and readily available, and which
only requires one experienced radiologist, is catheter fragmentation (as
referenced in our guidelines).
This first-class Boston group are well
placed to consider a study in which patients are randomised to these
different treatment groups, and may find that the less invasive options
are at least as effective as well as being more applicable to non-specialist centres.
References
(1) Eltzschig HK, Rosenberger P. Surgical Pulmonary Embolectomy [electronic response to British Thoracic Society guidelines for the management of suspected acute pulmonary embolism] thoraxjnl.com 2003 http://thorax.bmjjournals.com/cgi/eletters/58/6/470#66
I would be grateful if the PE Guidelines Development Committee could
clarify the validity of the pre-test probability (PTP) score which was
quoted in the 1997 guidelines for PE and which reappears in the latest PE
guidelines.
In the 1997 guidelines it clearly states that the suggested
PTP score had not been validated, but was derived from the works of others
in particular Wells in Canada. Howe...
I would be grateful if the PE Guidelines Development Committee could
clarify the validity of the pre-test probability (PTP) score which was
quoted in the 1997 guidelines for PE and which reappears in the latest PE
guidelines.
In the 1997 guidelines it clearly states that the suggested
PTP score had not been validated, but was derived from the works of others
in particular Wells in Canada. However, although the latest guideline
still refers to the simple PTP from 1997, none of the quoted references
supporting its use in this National guideline, have formally validated the
criteria. As so much emphasis is placed on the low or intermediate PTP
score, combined with the D-Dimer result, in many cases excluding patients
from further tests for PE, I wonder if we should be recommending a PTP
score which has not been validated in an unselected cohort of patients
with suspected or possible PE.
In his letter, Dr Devoy is questioning the strength of the conclusion in our publication regarding the clinical efficacy of salmeterol on dyspnea, quality of life and reductions of exacerbations.
We had stated that the effects with long-acting ß2-adrenergic
bronchodilators on COPD exacerbations and on other health outcomes has
provided inconsistent results [1] We note that Dr Devoy’s argument is
mo...
In his letter, Dr Devoy is questioning the strength of the conclusion in our publication regarding the clinical efficacy of salmeterol on dyspnea, quality of life and reductions of exacerbations.
We had stated that the effects with long-acting ß2-adrenergic
bronchodilators on COPD exacerbations and on other health outcomes has
provided inconsistent results [1] We note that Dr Devoy’s argument is
mostly based on two studies published very recently, one shortly before [2] and one at the same time [3] of our study, on one paper in press and
four abstracts. We believe it is optimal to restrict comments only to the
evidence arising from published full peer-reviewed papers. The recent
study by Mahler et al.[2] referenced by Dr Devoy showed no difference
between salmeterol and placebo regarding dyspnea, exacerbations, or health
status. A similar lack of efficacy on these health outcomes was observed
by Rennard et al.[4] Calverley et al.[3] showed slightly less
exacerbations, but no effects with regard to quality of life and dyspnea.
These findings do not change, but rather reinforce, our opinion that
salmeterol treatment in COPD gave inconsistent results.
Dr Devoy further questions the definition of exacerbations of COPD
used in our analysis, suggesting the use of health utilization or a
combination of major and minor symptoms. There is no general consensus
and a range of definitions have been used in the literature. Indeed, in at
least three studies describing the effect of salmeterol on exacerbations,
no definition at all is provided.[2,4,5] In our study, the definition of
exacerbation has been pre-specified, includes a minimal time frame (3
days) to eliminate the misinterpretation of day to day variability and
requires a minimum of two symptoms (new onset or increase in symptoms).
Using this exacerbation definition, 88-91% of COPD exacerbations in this
trial required the use of either antibiotics or oral corticosteroids or
both, indicating that the clinicians involved considered the vast majority
of these flare-ups to be clinically significant. The reduction seen with
tiotropium in our study is also supported by the reductions in COPD
exacerbations and associated hospitalizations observed in one-year trials,
the later outcome (hospitalizations) being an important outcome with
little debate.[6,7]
In conclusion the improvements in dyspnea, quality of life and
exacerbations with tiotropium have been consistently demonstrated [6,7]
whereas these outcomes with salmeterol are either absent or inconsistent
at best.
References
(1) Brusasco V, Hodder R, Miravitlles M, Korducki L, Towse L, Kesten S. Health outcomes following treatment for six months with once daily
tiotropium compared with twice daily salmeterol in patients with COPD. Thorax 2003;58:399-404 .
(2) Mahler DA, Wire P, Horstman D, Chang CN, Yates J, Fischer T, Shah T.
Effectiveness of fluticasone propionate and salmeterol combination
delivered via the Diskus device in the treatment of chronic obstructive
pulmonary disease. Am J Resp Crit Care Med 2002;166:1084-1091.
(3) Calverley P, Pauwels R, Vestbo J, Jones P, Pride N, Gulsvid A, Anderson
J, Maden C. Combined salmeterol and fluticasone in the treatment of
chronic obstructive pulmonary disease: a randomized controlled trial.
Lancet 2003;361:449-456.
(4) Rennard SI, Anderson W, ZuWallack R, Broughton J, Bailey W, Friedman M,
Wisniewski M, Rickard K. Use of a long-acting inhaled B2-adrenergic
agonist, salmeterol xinfoate in patients with chronic obstructive
pulmonary disease. Am J Resp Crit Care Med2001;163:1087-92.
(5) Chapman KR, Arvidsson P, Chuchalin AG, Dhillon DP, Faurschou P,
Goldstein RS, Kuipers AF. The addition of salmeterol 50 mcg bid to
anticholinergic treatment in patients with COPD: a randomized placebo
controlled trial. Can Respir J 2002;9:178-185.
(6) Casaburi R, Mahler DA, Jones PW, Wanner A, San Pedro G, ZuWallack RL,
Menjoge SS, Serby CW, Witek TJ. A long-term evaluation of once-daily
inhaled tiotropium in chronic obstructive pulmonary disease. Eur Respir J
2002;19(2):217-24.
(7) Vincken W, van Noord JA, Greefhorst APM, Bantje ThA, Kesten S, Korducki
L, Cornelissen PJG. Improved health outcomes in patients with COPD during
1 yr’s treatment with tiotropium. Eur Respir J 2002;19(2):209-16.
We would like to comment on strength of conclusions of the recent
publication by Dr Brusasco et al,[1] particularly that no consideration
is given to how the results compare to the balance of evidence that
exists.
The paper’s conclusions imply superior efficacy of tiotropium over
salmeterol in patients with COPD by emphasising endpoints in which
tiotropium shows a difference compar...
We would like to comment on strength of conclusions of the recent
publication by Dr Brusasco et al,[1] particularly that no consideration
is given to how the results compare to the balance of evidence that
exists.
The paper’s conclusions imply superior efficacy of tiotropium over
salmeterol in patients with COPD by emphasising endpoints in which
tiotropium shows a difference compared with placebo, but salmeterol does
not. However, as this combined analysis fails to show clinically relevant
differences between salmeterol and tiotropium we believe such conclusions
to be somewhat exaggerated.
We note that for certain endpoints, salmeterol in this analysis
failed to show a difference compared with placebo. While these results
were disappointing, they are not reflective of the wealth of evidence that
exists from previous placebo-controlled studies of up to 12 months
duration with salmeterol. These studies show significant improvements in
lung function, quality of life, breathlessness and reliever use, and
exacerbations compared with placebo/usual therapy.[2-9]
A recent meta-analysis of nine double-blind studies including over
3500 patients with COPD confirms that salmeterol has a significant and
sustained bronchodilator effect with no evidence of tolerance compared
with placebo, and significantly reduces the risk of exacerbations (22%
reduction compared with placebo/usual therapy).[9,10]
Lastly, and we feel importantly, this study and analysis introduces a
new definition of COPD exacerbations with no explanation for the
rationale, nor a justification for the validity of this. Previous studies
have either used health utilisation [2,11] (event measured is sufficiently
important for the patient to seek medical help and the physician to feel
the patient needs treatment), or exacerbations are defined by a
combination of major and minor symptoms.[12,13] By not using any of these
definitions, it is difficult for the clinician to evaluate any relative
efficacy of tiotropium in reducing exacerbations, compared to other
therapeutic agents currently available.
In conclusion, it is important to reflect on whether the findings of
this study are supported by what we already know. We feel it is important
to state that for this publication and for the results seen for
salmeterol, this is clearly not the case.
References
(1) Brusasco V, Hodder R, Miravitlles M, Korducki L, Towse L, Kesten S.
Health outcomes following treatment for six months with once daily
tiotropium compared with twice daily salmeterol in patients with COPD.
Thorax 2003;58:399-404.
(2) Calverley P, Pauwels R, Vestbo J, et al. Combined salmeterol and
fluticasone in the treatment of chronic obstructive pulmonary disease: a
randomised controlled trial. Lancet 2003;361:449–456.
(3) Mahler DA, Wire P, Horstman et al. Effectiveness of fluticasone
propionate and salmeterol combination delivered via the Diskus device in
the treatment of chronic obstructive pulmonary disease. Am J Respir Crit
Care Med 2002;166:1084-1091.
(4) Hanania NA, Knobil K, Watkins M, Wire P, Yates J, Darken P. The efficacy
and safety of fluticasone propionate 250mcg/salmeterol 50mcg combined in
the Diskus inhaler for the treatment of chronic obstructive pulmonary
disease. Chest 2003;in press.
(5) Stockley RA, Chopra N. Salmeterol, added to usual therapy is an
effective bronchodilator over 12 months of treatment in chronic
obstructive pulmonary disease (COPD). Eur Respir J 2002;20 (suppl
38):241s.
(6) Stockley RA, Davies EA, Sondhi S, Rice L. Salmeterol provides sustained
health status improvement over 12 months in patients with COPD. Eur Respir
J 2002;20(suppl 38):241s.
(7) Jones PW, Bosh TK. Quality of life changes in COPD patients treated with
salmeterol. Am J Respir Crit Care Med 1997;155:1283–1289.
(8) Boyd G, Morice AH, Pounsford JC, Siebert M, Peslis N, Crawford C. An
evaluation of salmeterol in the treatment of chronic obstructive disease.
Eur Respir J 1997;10(4):815–821.
(9) Stockley RA, Whitehead PJ, Williams MK, Hagan G. Serevent 50mcg bid
significantly reduces moderate-severe exacerbations in patients with all
severities of COPD. Am J Respir Crit Care Med 2003;167(7):A949.
(10) Stockley RA, Whitehead PJ, Williams MK, Hagan G. Serevent 50mcg bid
significantly increases trough FEV1 in COPD up to 12 months without loss
of effect. Am J Respir Crit Care Med 2003;167(7):A95.
(11) Szafranski W, Cukier A, Ramirez A et al. Efficacy and safety of
budesonide/formoterol in the management of chronic obstructive pulmonary
disease. Eur Respir J 2003;21:74-81.
(12) Anthonisen RN, Manfreda J, Warren CPW, Hershfield ES, Harding GKM,
Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive
pulmonary disease. Ann Intern Med 1987;106:196-204.
(13) Seemungal TAR, Donaldson GC, Bhowmik A et al. Time course and recovery
of exacerbations in patients with chronic obstructive pulmonary disease.
Am J Respir Crit Care Med 2000;161:1608-1613.
With great interest, we read the guidelines for the management of
suspected acute pulmonary embolism (PE) by the British Thoracic Society
(June issue 2003).[1] In the discussion of treatment options, the
guidelines state that surgical embolectomy should only be considered in
cases with absolute contraindications to thrombolysis, which is rarely an
important consideration in a life-threatening situat...
With great interest, we read the guidelines for the management of
suspected acute pulmonary embolism (PE) by the British Thoracic Society
(June issue 2003).[1] In the discussion of treatment options, the
guidelines state that surgical embolectomy should only be considered in
cases with absolute contraindications to thrombolysis, which is rarely an
important consideration in a life-threatening situation.
In contrast to the guidelines, a recent study of surgical pulmonary
embolectomy with the use of normothermic cardiopulmonary bypass
liberalized these criteria. Patients with anatomically extensive pulmonary
embolism and concomitant right heart failure were included and
demonstrated a 1-month mortality rate of only 11% following surgical
intervention.[2] The improved survival rates in this case series as
compared to previous reports [3,4] may be related to advances in surgical
technique, patient selection and the experience of cardiac surgeons and
cardiac anesthesiologists with this operation. However, this report no
longer confines surgical pulmonary embolectomy to a treatment of last
resort reserved for clinically desperate circumstances. In contrast,
centers that are experienced in performing pulmonary embolectomy may
consider utilizing this therapeutic intervention more liberal in order to
improve morbidity and mortality of patients suffering from severe PE.
References
(1) British Thoracic Society guidelines for the management of
suspected acute pulmonary embolism. Thorax 2003;58(6):470-483.
(2) Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute Pulmonary
Embolectomy: A Contemporary Approach. Circulation 2002;105(12):1416-1419.
(3) Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ,
3rd. Predictors of survival after deep vein thrombosis and pulmonary
embolism: a population-based, cohort study. Arch Intern Med 1999;159(5):445-53.
(4) Doerge H, Schoendube FA, Voss M, Seipelt R, Messmer BJ. Surgical
therapy of fulminant pulmonary embolism: early and late results. Thorac
Cardiovasc Surg 1999;47(1):9-13.
One of the paradoxes of modern medicine is the rapid growing
incidence of immune-based diseases over the last half of the century.
Despite enormous advances in our understanding of the immune system, and
our ability to manipulate immunity in experienced animals and man, we have
not been able to curtail these diseases. In fact, it is becoming
increasing evident that immune hypersensitivity response...
One of the paradoxes of modern medicine is the rapid growing
incidence of immune-based diseases over the last half of the century.
Despite enormous advances in our understanding of the immune system, and
our ability to manipulate immunity in experienced animals and man, we have
not been able to curtail these diseases. In fact, it is becoming
increasing evident that immune hypersensitivity responses are central to
the pathogenesis of many of the most common diseases of the 21st century
including atherosclerosis, diabetes, obesity, and arthritis . Included in
this epidemic are atopy-associated disorders (such as asthma, eczema,
allergic rhinoconjunctivitis, and food allergies), which have skyrocketed
in prevalence. While genetic factors certainly contribute to the
pathogenesis of these diseases, there is emerging evidence that their
rising incidence is related to changes in western lifestyle. ADAM 33, a
new asthma gene is a major breakthrough and would definitely help in the
management of asthma.
The efficacy and clinical effectiveness of homeopathy engenders
considerable debate; it is therefore essential that clinical trials are
accurately interpreted and reported. The recent publication by White et al.[1] has highlighted this issue.
The study, assessing classical homeopathy
as an adjunctive treatment for childhood asthma concluded that, based on
the primary outcome (the active qua...
The efficacy and clinical effectiveness of homeopathy engenders
considerable debate; it is therefore essential that clinical trials are
accurately interpreted and reported. The recent publication by White et al.[1] has highlighted this issue.
The study, assessing classical homeopathy
as an adjunctive treatment for childhood asthma concluded that, based on
the primary outcome (the active quality of living subscale of the
Childhood Asthma Questionnaire) classical homeopathy was not superior to
placebo. We disagree with this conclusion. The scale used to assess the
primary outcome was inappropriate [it does not distinguish between
asthmatics and non-asthmatics [2] and is more suitable as a cross-sectional
measure rather than a longitudinal outcome; and the ability to identify
any therapeutic improvement was severely reduced due to ceiling/flooring
effects in both the primary and some secondary outcome data. For example,
baseline scores identified that the study population had good quality of
life, and that two of the three age groups studied had mild asthma.
Therefore, any therapeutic improvement would be hard to identify let alone
quantify.
Other design issues were apparent, e.g. no data was reported on
homeopathic exacerbations (an indicator of the healing response), and the
security of blinding was not assessed. Yet despite these limitations, some
encouraging therapeutic effects were apparent. For example, a clinically
relevant improvement in asthma severity (unadjusted scores) was seen in
two of the three groups and a favourable pattern in the days off
school/days attended was seen in the homeopathic treated children
(although no data was presented).
We suggest that a balanced and accurate conclusion to this data would
be that no definitive conclusions could be drawn but that further
investigation is needed. We therefore hope that the authors’ inaccurate
conclusions neither dampens future research, nor bias future systematic
reviews.[3]
References
(1) White A, Slade P, Hunt C, Hart A and Ernst E. Individualised
homeopathy as an adjunct in the treatment of childhood asthma ;a
randomised placebo controlled trial. Thorax 2003: 58:317-321.
(2) French DJ, Christie MJ, Snowden AJ. The reproducibility of the
childhood asthma questionnaires: measures of aulity of life fro children
with asthma aged 4-16 years. Quality of Life Research 1994;3:215-224.
(3) White, P, Lewith G, Berman B and Birch S. Reviews of acupuncture for
chronic neck pain : pitfalls in conduting systematic reviews. Rheumatology
2002;41:1224–1231.
Dr Leckridge[1] is correct to state that the children in the study had
mild to moderate symptoms of asthma at the time of recruitment. Children
with more severe symptoms were excluded at the request of the Ethics
Committee, because of the risks that could arise if they stopped their
conventional medication. Our study tested homeopathy as an adjunct to
standard medical management, not an alternative.
Dr Leckridge[1] is correct to state that the children in the study had
mild to moderate symptoms of asthma at the time of recruitment. Children
with more severe symptoms were excluded at the request of the Ethics
Committee, because of the risks that could arise if they stopped their
conventional medication. Our study tested homeopathy as an adjunct to
standard medical management, not an alternative.
We expected that children
given homeopathy might be able to reduce their conventional medication by
standard guidelines, but could not find any evidence that this occurred.
We acknowledged that there were trends in favour of the homeopathy group
in some measures, but not in the primary measure, which was recommended by
the questionnaire’s author as the most sensitive to change. We were
careful not to over-generalise from our study, and certainly did not claim
that homeopathy is ineffective in different samples of patients with
asthma, for example those with more severe symptoms.
Reference
(1) Leckridge R. Homeopathy and childhood asthma [electronic response to White et al. Individualised homeopathy as an adjunct in the treatment of childhood asthma: a randomised placebo controlled trial] thoraxjnl.com 2003 http://thorax.bmjjournals.com/cgi/eletters/58/4/317#59
This study of quality of life in children with asthma treated with
homeopathy is fatally flawed.[1] The Childhood Asthma Quality of Life
instrument used was validated in a study by French et al.[2] The children entered into White’s study had
scores consistent with those of normal children who don’t have asthma. For
a statistically significant improvement to occur in this score, the
treated group wo...
This study of quality of life in children with asthma treated with
homeopathy is fatally flawed.[1] The Childhood Asthma Quality of Life
instrument used was validated in a study by French et al.[2] The children entered into White’s study had
scores consistent with those of normal children who don’t have asthma. For
a statistically significant improvement to occur in this score, the
treated group would have to develop scores of around 100% ie better than
normal, non-asthmatic children. This is clearly highly unlikely. In
addition, a similar “ceiling effect” applies to the PEFR readings – again,
at entry they were 100.4% and 96.9% of expected for the verum and placebo
groups, respectively.
This is a very poor quality trial which does absolutely nothing to further
our understanding of the potential value of homeopathic treatment in
children with asthma. In fact, the press release from the journal has been
picked up by the media and used to support a headline of “Homeopathy of no
use in Asthma”.
Publishing this quality of research at best does not improve our necessary
evidence base, and, at worst, contributes to the denial of services which
may indeed be of value to patients. A close analysis of the study shows
that the treatment group had a trend to better outcomes than the placebo
group. If this were a pilot study, it would be indicating that there is
indeed a potential benefit to asthmatic children from homeopathy which
should be investigated with a proper trial of good methodological quality.
References
(1) A White, P Slade, C Hunt, A Hart, and E Ernst. Individualised homeopathy as an adjunct in the treatment of childhood asthma: a randomised placebo controlled trial. Thorax 2003; 58:317-321.
(2) French DJ, Christie MJ, Sowden AJ. The reproducibility of the childhood asthma questionnaires: measures of quality of life for children with asthma aged 4–16 years. Qual Life Res 1994;3:215–24.
Dear Editor
Whilst one must of course take into account the mortality figures whilst treating multi-drug resistant tuberculosis, there may be other aspects that need to be studied. The collegues would to well perhaps to address some part of their research to the mortality of those patients who had been prescribed for a protected period antituberculous chemotherapy: (this can be for up to two years), and who have been m...
Dear Editor
The letter from Dr Eltzschig [1] refers to their paper showing that surgical embolectomy remains an option in severe pulmonary embolism. Firstly, this required "a multidisciplinary evaluation team with a widespread reputation for 24-hour availability, 7 days per week" (and over half of their patients had surgery during the weekend); there must be very few centres in the world who can offer such a service,...
Dear Editor
I would be grateful if the PE Guidelines Development Committee could clarify the validity of the pre-test probability (PTP) score which was quoted in the 1997 guidelines for PE and which reappears in the latest PE guidelines.
In the 1997 guidelines it clearly states that the suggested PTP score had not been validated, but was derived from the works of others in particular Wells in Canada. Howe...
Dear Editor
In his letter, Dr Devoy is questioning the strength of the conclusion in our publication regarding the clinical efficacy of salmeterol on dyspnea, quality of life and reductions of exacerbations. We had stated that the effects with long-acting ß2-adrenergic bronchodilators on COPD exacerbations and on other health outcomes has provided inconsistent results [1] We note that Dr Devoy’s argument is mo...
Dear Editor
We would like to comment on strength of conclusions of the recent publication by Dr Brusasco et al,[1] particularly that no consideration is given to how the results compare to the balance of evidence that exists.
The paper’s conclusions imply superior efficacy of tiotropium over salmeterol in patients with COPD by emphasising endpoints in which tiotropium shows a difference compar...
Dear Editor
With great interest, we read the guidelines for the management of suspected acute pulmonary embolism (PE) by the British Thoracic Society (June issue 2003).[1] In the discussion of treatment options, the guidelines state that surgical embolectomy should only be considered in cases with absolute contraindications to thrombolysis, which is rarely an important consideration in a life-threatening situat...
Dear Editor
One of the paradoxes of modern medicine is the rapid growing incidence of immune-based diseases over the last half of the century.
Despite enormous advances in our understanding of the immune system, and our ability to manipulate immunity in experienced animals and man, we have not been able to curtail these diseases. In fact, it is becoming increasing evident that immune hypersensitivity response...
Dear Editor
The efficacy and clinical effectiveness of homeopathy engenders considerable debate; it is therefore essential that clinical trials are accurately interpreted and reported. The recent publication by White et al.[1] has highlighted this issue.
The study, assessing classical homeopathy as an adjunctive treatment for childhood asthma concluded that, based on the primary outcome (the active qua...
Dear Editor
Dr Leckridge[1] is correct to state that the children in the study had mild to moderate symptoms of asthma at the time of recruitment. Children with more severe symptoms were excluded at the request of the Ethics Committee, because of the risks that could arise if they stopped their conventional medication. Our study tested homeopathy as an adjunct to standard medical management, not an alternative.
...Dear Editor
This study of quality of life in children with asthma treated with homeopathy is fatally flawed.[1] The Childhood Asthma Quality of Life instrument used was validated in a study by French et al.[2] The children entered into White’s study had scores consistent with those of normal children who don’t have asthma. For a statistically significant improvement to occur in this score, the treated group wo...
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