Correspondence
F i n a l l y, L a b r o p o u l o s a n d colleagues seem to be dismayed that the SOX trial does not confirm the assumed benefit of elastic compression stockings suggested by smaller trials. There are many examples of large, properly designed multicenter trials refuting results of earlier smaller trials or cohort studies.7 The SOX trial is the largest randomised trial so far of elastic compression stockings, overcomes the potential for bias inherent in any open trial by using placebo and double blinding, uses outcome measures used in other clinical trials of post-thrombotic syndrome, and is generalisable because of the large number of centres involved. Further, the estimated compliance rates are consistent with our clinical experience. Many patients find elastic compression stockings intolerable for aesthetic reasons, because they have the potential to cause discomfort, and can be difficult to put on. Although some might find the negative results of the SOX trial disappointing, patients might be relieved to find that they do not routinely need to wear elastic compression stockings for 2 years after deep-vein thrombosis. We declare no competing interests.
*Susan R Kahn, Stan Shapiro, Jeffrey S Ginsberg, for the SOX trial investigators [email protected]
4
5
6
7
Prandoni P, Lensing AWA, Prins MH, et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004; 141: 249–56. Brandjes DPM, Buller HR, Heijboer H, Hulsman MV, de Rijk M, Jagt H. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997; 349: 759–62. Raju S, Hollis K, Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy. Ann Vasc Surg 2007; 21: 790–95. Hennekens CH, DeMets D. The need for large-scale randomized evidence without undue emphasis on small trials, meta-analyses, or subgroup analyses. JAMA 2009; 302: 2361–62.
Twitter: an opportunity for public health campaigns Twitter is a popular medium for communication and information sharing with 200 million active users and 400 million tweets per day.1 Almost a third of internet users 18–24 years old use Twitter, and 20% use it daily.2 Indoor tanning, which is associated with an increased risk of skin cancer,3 has reached alarming rates among
young people, with about 20% of teenagers using indoor tanning.4 We assess the frequency of mentions of indoor tanning and tanning health risks on Twitter. We used the Twitter Streaming Application Programming Interface (API) to collect in real time all tweets (English language) mentioning indoor tanning, tanning bed, tanning booth, tanning salon, sun bed, or sun lamp, over 2 weeks (March 27, 2013, to April 10, 2013). Data are presented in the table. Over the 2-week collection period, 154 496 tweets mentioned indoor tanning: that is 7·7 per minute. The health themes mentioned in indoor tanning tweets are shown in the table. During the 2-week period, more than 120 000 individuals posted at least one tweet mentioning indoor tanning, potentially reaching more than 100 million individuals. Among these tweets, a very small percentage mentioned the health risks associated with indoor tanning, such as skin cancer. Because of Twitter’s broad reach, especially among young adults, health advocates should consider increasing the use of Twitter and other Number
Twitter users posting on indoor tanning
120 354
Tweets about indoor tanning
154 496
Followers exposed to tweets about indoor tanning
113 888 616
Tweets about indoor tanning, also mentioning:* Cancer (“cancer”, “carcinoma”, “melanoma”, “basal cell”, “squamous cell”)
3956 (2·56%)
“Burn”
7344 (4·75%)
“Danger”
288 (0·19%)
Centre for Clinical Epidemiology, Jewish General Hospital, 3755 Cote Ste Catherine Room H420.1, Montreal, QC H3T 1E2, Canada (SRK, SS); and Department of Medicine, McMaster University, Hamilton, ON, Canada (JSG)
“Itch”
2884 (1·87%)
Pain (“pain”, “hurt”, “ouch”, “ow”)
1856 (1·20%)
1
“Wrinkles” or “aging”
405 (0·26%)
“Vitamin”
196 (0·13%)
2
3
Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014; 383: 880–88. Kahn SR, Partsch H, Vedantham S, Prandoni P, Kearon C. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost 2009; 7: 879–83. Soosainathan A, Moore HM, Gohel MS, Davies AH. Scoring systems for the post-thrombotic syndrome. J Vasc Surg 2013; 57: 254–61.
www.thelancet.com Vol 384 July 12, 2014
Cost (“cost”, “expense”, “money”) Bans or taxes (“ban”, “prohibit”, “restrict”, “legal”, “tax”)
705 (0·46%) 4083 (2·64%)
Spray or sunless tanning (“spray tan”, “self tan”, “sunless tan”, “tanning lotion”)
4433 (2·87%)
Advertisement†
1940 (1·26%)
News
418 (0·27%)
Data are n or n (%). *Categories are non-exclusive (eg, a tweet that contained both “cancer” and “danger” is listed in both categories). Listed search terms also included case and punctuation variations as well as alternate endings (eg, “ban”, “bans”, “banning”, “banned”. †User name or description contains “tanning”, “salon”, “studio”, “spa”, or tweet text contains “% off”.
Table: Twitter data mentioning indoor tanning (March 27–April 10, 2013)
131
Correspondence
online platforms to communicate public health and cancer prevention messages. Research is needed to explore ways to direct health messages to social network users who discuss and search for risk behaviours online. Combining the expertise of skin cancer and health communication researchers, public health advocates, and social media experts might be necessary to develop the effective cancer prevention campaigns. M-MC serves as a consultant to Genentech Inc. The other authors declare no competing interests.
Mackenzie R Wehner, Mary-Margaret Chren, Melissa L Shive, Jack S Resneck Jr, Sherry Pagoto, Andrew B Seidenberg, *Eleni Linos [email protected] Department of Dermatology, University of California San Francisco, San Francisco, CA 941430808, USA (MRW, M-MC, JSR, EL); School of Medicine, Stanford University, Stanford, CA, USA (MRW); Department of Dermatology, University of California Los Angeles, Los Angeles, CA, USA (MLS); Department of Dermatology and Philip R Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, CA, USA (JSR); Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA (SP); and Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, USA (ABS) Published Online June 23, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61000-X
1
2
3
4
Smith A, Brenner J. Twitter use 2012. Pew Research Center, May 31, 2012. http:// pewinternet.org/~/media//Files/Reports/2012/ PIP_Twitter_Use_2012.pdf (accessed July 24, 2013). Gray NJ, Klein JD, Noyce PR, Sesselberg TS, Cantrill JA. Health information-seeking behaviour in adolescence: the place of the internet. Social Sc Med 2005; 60: 1467–78. Wehner MR, Shive ML, Chren MM, Han J, Qureshi AA, Linos E. Indoor tanning and nonmelanoma skin cancer: systematic review and meta-analysis. BMJ 2012; 345: e5909. Wehner MR, Chren M, Nameth D, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol 2014; 150: 390-400.
The tragedy of African migrants in Yemen As a consequence of deepening political turmoil in the Horn of Africa, according to the UN High Commissioner for Refugees (UNHCR) more than 260 000 people migrated to Yemen during 2011–13 in pursuit 132
of a better life in Yemen, or on their way to neighbouring Gulf countries.1 The number of migrants has been increasing during 2011–13, but there has been a notable decrease since 2013 because of the increased insecurity in Yemen. The trip across the Gulf of Aden is especially difficult, and some migrants drown on their journey to Yemen. Thousands of migrants are stranded in the northern region of Yemen waiting to be transferred illegally to Saudi Arabia, and many are exposed to poverty, homelessness, and abuse.2 In their recent report Yemen’s Torture Camps: Abuse of Migrants by Human Traffickers in a Climate of Impunity,3 Human Rights Watch describes the tragedy of Somalian and Ethiopian migrants in Yemen, and reports severe torture and coercion. The report highlights that authorities are failing in fighting human trafficking, and even worse they occasionally can even help traffickers. Yemen is facing a crisis in health care, security, and access to food and water; 54·5% of the population live below the poverty line and this proportion is continuously increasing.4 More than 308 000 of Yemeni migrants have returned from Saudi Arabia since July, 2013, due to tightening labor laws, as reported by the International Organization of Migration.5 These returns of Yemeni in Yemen has somehow restricted the ability of the Government to handle African migrants adequately. And, as reported by Human Rights Watch,3 the authorities stopped fighting migrant traffickers, because it was unable to provide the migrants with adequate food and shelter. To end this human disaster, Yemen must commit to the 1951 Refugee Convention6 on the rights of refugees. The international community and donor countries should aim to resolve this tragedy and support governmental and non-governmental organisations initiatives. Improving security and reducing bribery in Yemen will also be important to reduce trafficking.
We declare no competing interests.
*Abdulrahman A Al-Khateeb, Ahmed S Bux, Ahmed M Fothan, Abdulrahman M Bakather, Hassan A Alqattan [email protected] College of Medicine, Alfaisal University, 11533 Riyadh, Saudi Arabia 1
2
3
4
5
6
UNHCR. New arrivals in Yemen comparison 2011–2014. http://reliefweb.int/map/yemen/ new-arrivals-yemen-comparison-2011-201431-march-2014 (accessed June 24, 2014). OCHA. Yemen: addressing the plight of migrants from the Horn of Africa. http://www. unocha.org/top-stories/all-stories/yemenaddressing-plight-migrants-horn-africa-0 (accessed June 24, 2014). Human Rights Watch. Yemen’s Torture Camps’: Abuse of Migrants by Human Traffickers in a Climate of Impunity. http://www.hrw.org/ node/125458 (accessed June 24, 2014). World Bank. Yemen overview. http://www. worldbank.org/en/country/yemen/overview (accessed June 24, 2014). International Organization of Migration. Yemeni migrants returned from Saudi Arabia through the Border Crossing Point of Al Tuwal, Hajjah–28 February 2014 Update. http://www. iom.int/files/live/sites/iom/files/Country/ docs/2014-02-28-Yemeni_Migrant_Snapshot. pdf (accessed June 24, 2014). UNHCR. The 1951 Refugee Convention. http://www.unhcr.org/pages/49da0e466. html (accessed June 24, 2014).
Department of Error Lawn JE, Blencowe H, Oza S, et al, for The Lancet Every Newborn Study Group. Progress, priorities, and potential beyond survival. Lancet 2014; published online May 20. http://dx.doi. org/10.1016/S0140-6736(14)60496-7—In this Series paper, the title should have read “Every Newborn: progress, priorities, and potential beyond survival”. In the third paragraph under the “Setting of neonatal mortality targets for 2035” heading, in the second sentence, the APR under-5 mortality target should have been “20 or fewer per 1000 livebirths”. Also, the second paragraph under the “Which causes of death to focus on” heading, should have read “Globally in 2012, complications from preterm birth (1·03 million, 36%), intrapartum-related conditions (previously called birth asphyxia; 0·66 million, 23%), and infections (notably sepsis, meningitis, and pneumonia; 0·66 million, 23%) were the main causes of neonatal deaths. Intrapartum-related conditions (27%) and preterm birth (41%) dominated in the early neonatal period, and infections (48%) were common in the late period (figure 6).” Additionally, in the second sentence of the Conclusion, the percentage for major effect should have been 71%. The supplementary appendix of this Series paper has been corrected. These changes have been made to the online version as of June 23, 2014, and to the printed paper.
www.thelancet.com Vol 384 July 12, 2014
F i n a l l y, L a b r o p o u l o s a n d colleagues seem to be dismayed that the SOX trial does not confirm the assumed benefit of elastic compression stockings suggested by smaller trials. There are many examples of large, properly designed multicenter trials refuting results of earlier smaller trials or cohort studies.7 The SOX trial is the largest randomised trial so far of elastic compression stockings, overcomes the potential for bias inherent in any open trial by using placebo and double blinding, uses outcome measures used in other clinical trials of post-thrombotic syndrome, and is generalisable because of the large number of centres involved. Further, the estimated compliance rates are consistent with our clinical experience. Many patients find elastic compression stockings intolerable for aesthetic reasons, because they have the potential to cause discomfort, and can be difficult to put on. Although some might find the negative results of the SOX trial disappointing, patients might be relieved to find that they do not routinely need to wear elastic compression stockings for 2 years after deep-vein thrombosis. We declare no competing interests.
*Susan R Kahn, Stan Shapiro, Jeffrey S Ginsberg, for the SOX trial investigators [email protected]
4
5
6
7
Prandoni P, Lensing AWA, Prins MH, et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004; 141: 249–56. Brandjes DPM, Buller HR, Heijboer H, Hulsman MV, de Rijk M, Jagt H. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997; 349: 759–62. Raju S, Hollis K, Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy. Ann Vasc Surg 2007; 21: 790–95. Hennekens CH, DeMets D. The need for large-scale randomized evidence without undue emphasis on small trials, meta-analyses, or subgroup analyses. JAMA 2009; 302: 2361–62.
Twitter: an opportunity for public health campaigns Twitter is a popular medium for communication and information sharing with 200 million active users and 400 million tweets per day.1 Almost a third of internet users 18–24 years old use Twitter, and 20% use it daily.2 Indoor tanning, which is associated with an increased risk of skin cancer,3 has reached alarming rates among
young people, with about 20% of teenagers using indoor tanning.4 We assess the frequency of mentions of indoor tanning and tanning health risks on Twitter. We used the Twitter Streaming Application Programming Interface (API) to collect in real time all tweets (English language) mentioning indoor tanning, tanning bed, tanning booth, tanning salon, sun bed, or sun lamp, over 2 weeks (March 27, 2013, to April 10, 2013). Data are presented in the table. Over the 2-week collection period, 154 496 tweets mentioned indoor tanning: that is 7·7 per minute. The health themes mentioned in indoor tanning tweets are shown in the table. During the 2-week period, more than 120 000 individuals posted at least one tweet mentioning indoor tanning, potentially reaching more than 100 million individuals. Among these tweets, a very small percentage mentioned the health risks associated with indoor tanning, such as skin cancer. Because of Twitter’s broad reach, especially among young adults, health advocates should consider increasing the use of Twitter and other Number
Twitter users posting on indoor tanning
120 354
Tweets about indoor tanning
154 496
Followers exposed to tweets about indoor tanning
113 888 616
Tweets about indoor tanning, also mentioning:* Cancer (“cancer”, “carcinoma”, “melanoma”, “basal cell”, “squamous cell”)
3956 (2·56%)
“Burn”
7344 (4·75%)
“Danger”
288 (0·19%)
Centre for Clinical Epidemiology, Jewish General Hospital, 3755 Cote Ste Catherine Room H420.1, Montreal, QC H3T 1E2, Canada (SRK, SS); and Department of Medicine, McMaster University, Hamilton, ON, Canada (JSG)
“Itch”
2884 (1·87%)
Pain (“pain”, “hurt”, “ouch”, “ow”)
1856 (1·20%)
1
“Wrinkles” or “aging”
405 (0·26%)
“Vitamin”
196 (0·13%)
2
3
Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014; 383: 880–88. Kahn SR, Partsch H, Vedantham S, Prandoni P, Kearon C. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost 2009; 7: 879–83. Soosainathan A, Moore HM, Gohel MS, Davies AH. Scoring systems for the post-thrombotic syndrome. J Vasc Surg 2013; 57: 254–61.
www.thelancet.com Vol 384 July 12, 2014
Cost (“cost”, “expense”, “money”) Bans or taxes (“ban”, “prohibit”, “restrict”, “legal”, “tax”)
705 (0·46%) 4083 (2·64%)
Spray or sunless tanning (“spray tan”, “self tan”, “sunless tan”, “tanning lotion”)
4433 (2·87%)
Advertisement†
1940 (1·26%)
News
418 (0·27%)
Data are n or n (%). *Categories are non-exclusive (eg, a tweet that contained both “cancer” and “danger” is listed in both categories). Listed search terms also included case and punctuation variations as well as alternate endings (eg, “ban”, “bans”, “banning”, “banned”. †User name or description contains “tanning”, “salon”, “studio”, “spa”, or tweet text contains “% off”.
Table: Twitter data mentioning indoor tanning (March 27–April 10, 2013)
131
Correspondence
online platforms to communicate public health and cancer prevention messages. Research is needed to explore ways to direct health messages to social network users who discuss and search for risk behaviours online. Combining the expertise of skin cancer and health communication researchers, public health advocates, and social media experts might be necessary to develop the effective cancer prevention campaigns. M-MC serves as a consultant to Genentech Inc. The other authors declare no competing interests.
Mackenzie R Wehner, Mary-Margaret Chren, Melissa L Shive, Jack S Resneck Jr, Sherry Pagoto, Andrew B Seidenberg, *Eleni Linos [email protected] Department of Dermatology, University of California San Francisco, San Francisco, CA 941430808, USA (MRW, M-MC, JSR, EL); School of Medicine, Stanford University, Stanford, CA, USA (MRW); Department of Dermatology, University of California Los Angeles, Los Angeles, CA, USA (MLS); Department of Dermatology and Philip R Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, CA, USA (JSR); Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA (SP); and Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, USA (ABS) Published Online June 23, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61000-X
1
2
3
4
Smith A, Brenner J. Twitter use 2012. Pew Research Center, May 31, 2012. http:// pewinternet.org/~/media//Files/Reports/2012/ PIP_Twitter_Use_2012.pdf (accessed July 24, 2013). Gray NJ, Klein JD, Noyce PR, Sesselberg TS, Cantrill JA. Health information-seeking behaviour in adolescence: the place of the internet. Social Sc Med 2005; 60: 1467–78. Wehner MR, Shive ML, Chren MM, Han J, Qureshi AA, Linos E. Indoor tanning and nonmelanoma skin cancer: systematic review and meta-analysis. BMJ 2012; 345: e5909. Wehner MR, Chren M, Nameth D, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol 2014; 150: 390-400.
The tragedy of African migrants in Yemen As a consequence of deepening political turmoil in the Horn of Africa, according to the UN High Commissioner for Refugees (UNHCR) more than 260 000 people migrated to Yemen during 2011–13 in pursuit 132
of a better life in Yemen, or on their way to neighbouring Gulf countries.1 The number of migrants has been increasing during 2011–13, but there has been a notable decrease since 2013 because of the increased insecurity in Yemen. The trip across the Gulf of Aden is especially difficult, and some migrants drown on their journey to Yemen. Thousands of migrants are stranded in the northern region of Yemen waiting to be transferred illegally to Saudi Arabia, and many are exposed to poverty, homelessness, and abuse.2 In their recent report Yemen’s Torture Camps: Abuse of Migrants by Human Traffickers in a Climate of Impunity,3 Human Rights Watch describes the tragedy of Somalian and Ethiopian migrants in Yemen, and reports severe torture and coercion. The report highlights that authorities are failing in fighting human trafficking, and even worse they occasionally can even help traffickers. Yemen is facing a crisis in health care, security, and access to food and water; 54·5% of the population live below the poverty line and this proportion is continuously increasing.4 More than 308 000 of Yemeni migrants have returned from Saudi Arabia since July, 2013, due to tightening labor laws, as reported by the International Organization of Migration.5 These returns of Yemeni in Yemen has somehow restricted the ability of the Government to handle African migrants adequately. And, as reported by Human Rights Watch,3 the authorities stopped fighting migrant traffickers, because it was unable to provide the migrants with adequate food and shelter. To end this human disaster, Yemen must commit to the 1951 Refugee Convention6 on the rights of refugees. The international community and donor countries should aim to resolve this tragedy and support governmental and non-governmental organisations initiatives. Improving security and reducing bribery in Yemen will also be important to reduce trafficking.
We declare no competing interests.
*Abdulrahman A Al-Khateeb, Ahmed S Bux, Ahmed M Fothan, Abdulrahman M Bakather, Hassan A Alqattan [email protected] College of Medicine, Alfaisal University, 11533 Riyadh, Saudi Arabia 1
2
3
4
5
6
UNHCR. New arrivals in Yemen comparison 2011–2014. http://reliefweb.int/map/yemen/ new-arrivals-yemen-comparison-2011-201431-march-2014 (accessed June 24, 2014). OCHA. Yemen: addressing the plight of migrants from the Horn of Africa. http://www. unocha.org/top-stories/all-stories/yemenaddressing-plight-migrants-horn-africa-0 (accessed June 24, 2014). Human Rights Watch. Yemen’s Torture Camps’: Abuse of Migrants by Human Traffickers in a Climate of Impunity. http://www.hrw.org/ node/125458 (accessed June 24, 2014). World Bank. Yemen overview. http://www. worldbank.org/en/country/yemen/overview (accessed June 24, 2014). International Organization of Migration. Yemeni migrants returned from Saudi Arabia through the Border Crossing Point of Al Tuwal, Hajjah–28 February 2014 Update. http://www. iom.int/files/live/sites/iom/files/Country/ docs/2014-02-28-Yemeni_Migrant_Snapshot. pdf (accessed June 24, 2014). UNHCR. The 1951 Refugee Convention. http://www.unhcr.org/pages/49da0e466. html (accessed June 24, 2014).
Department of Error Lawn JE, Blencowe H, Oza S, et al, for The Lancet Every Newborn Study Group. Progress, priorities, and potential beyond survival. Lancet 2014; published online May 20. http://dx.doi. org/10.1016/S0140-6736(14)60496-7—In this Series paper, the title should have read “Every Newborn: progress, priorities, and potential beyond survival”. In the third paragraph under the “Setting of neonatal mortality targets for 2035” heading, in the second sentence, the APR under-5 mortality target should have been “20 or fewer per 1000 livebirths”. Also, the second paragraph under the “Which causes of death to focus on” heading, should have read “Globally in 2012, complications from preterm birth (1·03 million, 36%), intrapartum-related conditions (previously called birth asphyxia; 0·66 million, 23%), and infections (notably sepsis, meningitis, and pneumonia; 0·66 million, 23%) were the main causes of neonatal deaths. Intrapartum-related conditions (27%) and preterm birth (41%) dominated in the early neonatal period, and infections (48%) were common in the late period (figure 6).” Additionally, in the second sentence of the Conclusion, the percentage for major effect should have been 71%. The supplementary appendix of this Series paper has been corrected. These changes have been made to the online version as of June 23, 2014, and to the printed paper.
www.thelancet.com Vol 384 July 12, 2014
