Correspondence

Several international organisations have been engaged in North Korea for many years, and still there are grave, morally unacceptable, health inequities in the country. To ensure the right to health for all people of North Korea, increased academic collaboration could be a small step on the way to success. Reliable knowledge of a state’s health challenges and health system could help planning of health services, interventions, and humanitarian aid programmes.

Department of Community Medicine, Institute of Health and Society, University of Oslo, 0318 Oslo, Norway

more responsible and positive part in dealing with this issue instead of simply rejecting this accusation or opposing the politicisation of such issues.3 First, it is necessary to distinguish refugees from citizens who have entered China illegally for economic reasons. China must protect refugees’ basic rights, treat them with dignity, and stop repatriating them too easily. Second, China should take the comments and suggestions from the international community more seriously, working together, not only to contribute to humanitarian relief, but also to work to end the undeniable and unacceptable suffering of North Korea’s people. It is China’s responsibility and duty.

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We declare that we have no competing interests.

We declare that we have no competing interests.

*Espen Bjertness, Ahmed Ali Madar [email protected]

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The Lancet. North Korea: evidence of intolerable human rights violations. Lancet 2014; 383: 756. Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Yo Han Lee, Seok-Jun Yoon, Young Ae Kim, Ji Won Yeom, In-Hwan Oh. Overview of the burden of diseases in North Korea. J Prev Med Public Health 2013; 46: 111–17. United Nations Children’s Fund. Levels and trends in child mortality: report 2012. http:// www.childinfo.org/files/Child_Mortality_ Report_2012.pdf (accessed March 13, 2014). WHO. Levels and trends in child malnutrition: UNICEF-WHO-The World Bank joint child malnutrition estimates. http://www.who.int/ nutgrowthdb/jme_unicef_who_wb.pdf (accessed March 13, 2014). WHO. Noncommunicable disease country profiles: Democratic People’s Republic of Korea. http://www.who.int/nmh/countries/ prk_en.pdf?ua=1 (accessed March 13, 2014). WHO. Tuberculosis county profiles: Democratic People’s Republic of Korea. http://www.who. int/tb/country/en/index.html (accessed March 13, 2014).

We read with interest The Lancet’s Editorial on North Korea and evidence of intolerable human rights violations.1 As Chinese health-care professionals, we share The Lancet’s concerns about the situation in our neighbouring country, North Korea. Only a few people know what exactly happens there due to extremely limited news coverage. Since the evidence is solid after a year-long investigation into systematic human rights violations in North Korea,2 it is urgent that China plays a 1382

Cai-Yue Liu, An-Tang Liu, Hua-Peng Guan, *Hua Jiang [email protected] Department of Plastic and Reconstructive Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China (C-YL, A-TL, HJ); and Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, China (H-PG) 1

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The Lancet. North Korea: evidence of intolerable human rights violations. Lancet 2014; 383: 756. UN’s Human Rights Council. Commission of Inquiry on human rights in the Democratic People’s Republic of Korea, UN’s Human Rights Council. http://www.ohchr.org/EN/HRBodies/ HRC/CoIDPRK/Pages/Reportofthe CommissionofInquiryDPRK.aspx (accessed Feb 17, 2014). Agence France-Press. China rejects complicity in North Korea human rights violations. The Globalpost, Feb 18, 2014. http://www. globalpost.com/dispatch/news/regions/asiapacific/china/140218/china-rejectscomplicity-north-korea-human-rights-vi (accessed Feb 18, 2014).

Treatment of paracetamol overdose We read with interest David Bateman and colleagues’ report (Feb 22, p 697)1 regarding reduction of adverse effects during treatment with intravenous acetylcysteine for paracetamol poisoning. Acute ingestions of para cetamol are common and consequently it has become one of

the most frequent causes of acute liver failure in the USA. As such, efforts to reduce treatment-related adverse events and the overall costs of care are greatly needed. However, we are concerned about the generalisability of the protocol used by Bateman and colleagues. A new acetylcysteine protocol that reduces the minimum duration of treatment from 21 h to 12 h is appealing in the common setting of hospital overcrowding. While deserving of investigation, this justification alone is insufficient to advocate for the widespread adoption of this protocol. Although the present study effectively evaluates adverse events related to treatment, it was not powered for efficacy. We are specifically concerned about the use of shortened protocols in patients who either present later than 8 h after ingestion or with very high paracetamol concentrations such that substantial amounts of paracetamol would remain at the end of 12 h of therapy. We commend the authors for their elegant first step but caution that without efficacy data the risks of reducing care might outweigh the benefits. We agree that shortened therapeutic courses seem reasonable in patients who present early with paracetamol concentrations minimally above the treatment threshold, but strongly caution against abandonment of a treatment protocol that has been proven to be largely safe and effective until sound efficacy data are obtained. We declare that we have no competing interests.

*Benjamin Kessler, Robert Hoffman [email protected] Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA (BK); and Division of Medical Toxicology, Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA (RH) 1

Bateman DN, Dear DW, Thanacoody HKR, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial. Lancet 2014; 383: 697–704.

www.thelancet.com Vol 383 April 19, 2014

Treatment of paracetamol overdose.

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