Dear editor We have read the paper by Asmelash et al 1 with great interest. In Pakistan, the religious pundits enjoy a huge following as well, coherent with this fact we would like to share our viewpoint towards the study. This study was conducted when COVID-19 was peaking around the world, which is during May and June. It is the right time to analyze the Knowledge, Attitude, and Practices (KAP) of populations especially when morbidity and mortality were heightened. Moreover, it can inform decision-makers for the second wave for which large-scale lockdowns and curfew seem especially impossible for developing countries and prevention and control of the virus will largely rely on the KAP of populations. We suspect that due to the cross-sectional nature of this investigation, there lies a risk of social desirability bias from the side of the participants when they were assessed for their attitude and practices. Hence a longitudinal and task-based approach to assess these qualities could give more reliable results. This research included 260 married individuals as opposed to 150 single, widowed or separated individuals. Therefore, any responses from the married participants would be dominant over those of the other group's individuals. Due to this, we propose that a stratified random sampling method should be used in this regard to help in relating the responses in a correct balance. In Pakistan, religious leaders were seen actively taking part in the creation of awareness and instructing the public to follow the government's stay-at-home orders. 2 In the further battle against COVID-19 a strong coalition should be maintained between governments and other groups of people, especially in nations where they have large following, to smartly and effectively work towards prevention and control of the virus. The infodemic was likewise rampant in Pakistan. As in Ethiopia, the religious clergy believed that COVID-19 was the wrath of God, in Pakistan, the citizens took COVID-19 as mild flu, religious propaganda, governmental propaganda, a bioweapon or microchip to control humans and the influence of 5G mobile networks, etc. 3 The sound prevention and control efforts should also include adequate check and balance of these unattested beliefs and stereotypes.
We have read the article by He et al 1 with great interest and we appreciate and congratulate the authors on their findings of a single independent prognostic factor in breast cancer. Breast cancer is an emerging disease worldwide, and claims the lives of many women each year. Hence, identifying better prognostic factors for breast cancer has now become the need of time.In the inclusion criteria of this study, the authors mentioned that 134 Xanthous females with breast cancer were included. Apart from this, it should be considered whether the female participants were lactating or not, as lactation can prove to be a confounder as well as a positive prognostic factor. Studies have shown a negative association between lactation and breast cancer, so lactating women are less likely to develop breast cancer and even if they get the disease, they have a better prognosis as compared to non-lactating women. 2 Although lactate dehydrogenase to albumin ratio (LAR) can be used as a single prognostic factor in breast cancer patients, the validation of this outcome is questionable due to single-time evaluation pre-operatively.The authors studied progression-free survival among breast cancer patients based on a combination of different immune and inflammatory biomarkers. However, C-reactive protein which is a vital inflammatory marker is not mentioned, but if considered could have a big influence on the results of this study. Moreover, different studies proved a high association of C-reactive protein with breast cancer. 3 In this study, for assessing inflammatory markers, blood was selected as a medium. Breast tissue is extensively drained by the lymphatic system. Assessing inflammatory markers from lymphatic drainage, like fine-needle aspiration of lymphatic fluid, can provide valuable information about the presence and progression of breast cancer. Studies have shown that lymphatic assessment gives more reliable results in predicting overall survival in breast cancer patients. 4 The authors followed up the cases for progression-free survival until 45 months after surgery, which is less than 4 years. A period of this duration just means that the said prognostic biomarkers could prove to be good independent prognostic factors in terms of causing remission for less than 4 years. However, it is still open to debate if the prognostic factors of platelet count to lymphocyte count ratio, monocyte count to lymphocyte ratio, and LAR have a curative value or not, which requires at least 5 years of follow-up.
We have read the paper entitled "Effects of Grit on the Academic Performance of Medical Students" by Alzerwi 1 published in Advances in Medical Education and Practice. We congratulate and thank the author for bringing this issue, and followup to the article.The data for this study were collected when the students were beginning their academic year, and also because this study is a cross-sectional study, the participants referred to their previous year's activities in the survey. Hence, the question arises of whether their current grit scores has affected their performance or the activities left them with their current grit scores. Therefore, based on this study it is uncertain to use grit scores in predicting especially the academic properties of the participants.Grit scores can also secondarily predict other important outcomes 2 like passion and aim for pursuing medicine in the future. This can help in addressing an important issue of abandonment of practice by female graduates, influenced by family pressure, in Pakistan, 3 and also reduce the number of drop-outs by enrolling only the most dedicated applicants.The author did not brief about the questions he used in the questionnaire to illustrate how he matched perseverance and distraction to grit. Moreover, questions about aspired specialty could also be included in the survey because the specialties do give an idea about the resilience of the applicants.Saudi Arabia is a male-dominant country with under-representation of females in the workforce, requiring them to be more resilient to achieve the desired positions in the society, can also be attributed to the results highlighted in this study of females proving to be grittier than their male counterparts even though they showed less research participation.While noticing that the p-value given in this article when the author compared grit scores with age was p=0.22, the author having found no significant correlation between the two, we went on to seek the literature and found that Pena and Duckworth 4 in their study have identified a positive relationship between absolute age and grit-perseverance subscale with a p-value of p<0.001.The author discussed the reason for lower academic performance and higher repeat status of clinical students being summative assessments that are more
Dear editor We have read the paper by Alumran 1 on the benefits of precautionary measures seen in Saudi Arabia. We congratulate the author on their findings. Simultaneously, being concerned that extreme measures can be unfavorable to the public or impossible in some nations, we want to share our outlook on the study. This study was submitted on the 12th of May when the peak had not arrived in many countries. In July, we are seeing countries coming out of the pandemic. For a worse second wave apprehended, prolonged lockdowns supported in this study would be impossible. Alternatively, early screening of cases entwined with the public being able to suspect infection by the early phase symptoms of the infection, as extracted from the UK's COVID-19 Symptom Study App or other records, and then working on the test, trace and isolate system could thwart the dreaded second wave. The reproductive number (R o) used in this study had been derived by observing the documented cases. Asymptomatic cases could also be contagious and hence affect the R o. Inculcating the new-found R o , issued by wide-scale testing, that also includes the contagiousness of asymptomatic cases can give a clearer picture. Besides comorbidities and age composition, the imported strain of the virus, HLA types of a population, and other community-level confounders like the local epidemic record, which can inform about the drug intake of a population, can affect the case fatality rate across different populations. This study provides evidence that due to lockdown and screening for asymptomatic cases both positive cases and mortality can be diluted against the expected. Conversely, unintended reactions to intense precautionary measures like prevalent desperation among families due to visiting restrictions thrust by hospitals 2 and possible Post-traumatic Stress Disorder in the post-COVID-19 era are also real. Turning the focus toward least restrictive measures. Questions have arisen on the usefulness of quarantine for highly transmissible diseases due to its accompanying laws and limitations. 3 Moreover, countries like South Korea, Hong Kong, Singapore, Taiwan, and Japan did not execute draconian measures of lockdowns but rather buildup their test, trace and isolate system initially in the pandemic and successfully controlled the virus. The author highlighted the importance of public awareness. We will have to make sure that public awareness is being done on different grounds. Elective surgery patients are delaying their surgery mainly due to the overwhelming draconian pre-op quarantine
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