Dear Editor,

I wholeheartedly support Majeed and Abbasi's timely call to replace "non-pharmaceutical interventions" (NPIs) with "public health and social measures" (PHSMs) (1). This shift in terminology is more than semantics; it is essential in recognising the intrinsic value and complexity of public health approaches. Language shapes perception, and the term NPI inherently positions PHSMs as secondary to pharmaceutical solutions, undermining public health's fundamental role in disease prevention and health promotion.

PHSMs are not adjuncts to medical care; they are foundational to effective health systems. The COVID-19 pandemic starkly illustrated this reality. Long before vaccines and antiviral treatments were available, PHSMs such as contact tracing, hand hygiene, and social distancing were the primary tools for pandemic mitigation (2). Dismissing them as NPIs suggests they are of lesser importance when they are often the first line of defence against emerging health threats.

Moreover, PHSMs extend beyond infectious disease control. The growing burden of noncommunicable diseases (NCDs)—cardiovascular disease, diabetes, and chronic respiratory illnesses—highlights the necessity of robust public health strategies. Addressing risk factors like tobacco use, unhealthy diets, and sedentary lifestyles requires comprehensive public health interventions, not just pharmaceutical treatments (3). By adopting the PHSM framework, we underscore the proactive, preventive nature of these strategies rather than relegating them to a secondary role.

This article rightly highlights the addressal of the ‘wider determinants of health’ (4). The biomedical model of disease, while crucial, often overlooks broader social and behavioural dimensions. Using the term PHSM encourages a holistic perspective, recognising the interplay between wider determinants and health outcomes (5).

Housing, employment, and healthcare access disparities significantly influence infection rates and mortality. Low-income communities face higher risks due to overcrowded living conditions and limited remote work options. PHSMs addressing these disparities—like targeted public health messaging, income support policies, and workplace protections—demonstrate the necessity of integrating social measures into health responses (6).

The re-framing of public health terminology must extend to medical education for training future doctors to appreciate the interspersion of clinical medicine and public health. Medical journals should not only adopt PHSMs as standard terminology but also promote research exploring their multifaceted nature.

Modern medical curricula must integrate public health perspectives to address the rising burden of NCDs and the increasing strain on health systems due to unfavourable doctor-patient ratios. As healthcare systems globally grapple with limited resources, prioritising prevention reduces disease prevalence and hospitalisations. Preventative services are underutilised despite their effectiveness in reducing the human and economic burden of chronic diseases (7). Public health’s complexity must be acknowledged and valued, ensuring doctors are equipped for systemic interventions that improve population health outcomes sustainably.

"Public health and social measures" reflects the value, complexity, and vital role of these interventions in protecting population health. Embracing this terminology is not just an academic exercise—it is a necessary shift ensuring public health is respected and integrated into medical education. Moving beyond outdated distinctions affirms that public health is not secondary to medicine; it is an essential component of it.

References
1. Majeed A, Abbasi K. Medical journals should use the term “public health and social measures”. BMJ. 2025;388:r409.
2. World Health Organization. Public health and social measures during health emergencies [Internet]. Geneva: WHO; [cited 2025 Mar 28]. Available from: https://www.who.int/initiatives/who-public-health-and-social-measures-in...
3. World Health Organization. Noncommunicable diseases [Internet]. Geneva: WHO; [cited 2025 Mar 28]. Available from: https://www.who.int/health-topics/noncommunicable-diseases#tab=tab_1
4. Public Health England. Health Profile for England 2018: Chapter 6 - Wider determinants of health [Internet]. London: UK Government; 2018 [cited 2025 Mar 28]. Available from: https://www.gov.uk/government/publications/health-profile-for-england-20...
5. World Health Organization. Public health and social measures: Concept and framework [Internet]. Geneva: WHO; 2022 [cited 2025 Mar 28]. Available from: https://cdn.who.int/media/docs/default-source/documents/epp/phsm/phsm-co...
6. World Health Organization. New evidence review of social protection, public health, and social measures during emergencies [Internet]. Geneva: WHO; 2024 Dec 12 [cited 2025 Mar 28]. Available from: https://www.who.int/news/item/12-12-2024-new-evidence-review-of-social-p...
7. Centers for Disease Control and Prevention. Use of selected preventive health services among adults—United States, 2019 [Internet]. Atlanta: CDC; 2019 [cited 2025 Mar 28]. Available from: https://www.cdc.gov/pcd/issues/2019/18_0625.htm

Dear Editor

We read with interest the individual participant data meta-analysis by Jones et al. (BMJ 2025;388:e080507) examining the effects of intensive blood pressure (BP) treatment on orthostatic hypertension. While the study provides valuable insights into a poorly understood clinical phenomenon, several methodological and conceptual limitations warrant discussion.

First, the merging of trials with fundamentally different designs-goal-directed BP trials and placebo-controlled trials introduces significant heterogeneity. The pathophysiological mechanisms and treatment effects in placebo-controlled trials (e.g., initiating therapy in untreated patients) differ markedly from goal-directed trials (e.g., intensifying therapy in partially treated patients). Pooling these may obscure critical distinctions, as evidenced by the moderate heterogeneity (I²=38%) and divergent effect sizes between trial types (OR 0.95 for goal trials vs. 0.87 for placebo trials). Prior work emphasizes that such heterogeneity undermines the validity of pooled estimates unless rigorously addressed through stratified analyses or meta-regression.¹

Second, the definition of orthostatic hypertension remains contentious. The study uses a ≥20/10 mmHg rise in systolic/diastolic BP upon standing, but recent consensus guidelines propose combining this threshold with standing systolic BP ≥140 mmHg to improve specificity.² Notably, only 1.9% of participants met the latter criterion at baseline, suggesting most cases identified by the authors represent transient BP fluctuations rather than sustained orthostatic hypertension. This discrepancy risks conflating physiological variability with pathological phenotypes, limiting clinical applicability.

Third, the analysis lacks long-term clinical outcome data. While the study reports reduced odds of orthostatic hypertension with intensive treatment, the clinical significance of this finding remains unclear. Orthostatic hypertension has been linked to cardiovascular events and mortality in observational studies,³ but whether treatment-mediated reductions in orthostatic hypertension translate to lower risks of these outcomes requires validation. Without such data, the implications for practice remain speculative.

Fourth, subgroup analyses-particularly the larger treatment effect in non-Black individuals and those without diabetes-raise concerns about residual confounding. These subgroups may differ systematically in comorbidities, medication adherence, or autonomic function, none of which were adequately adjusted for. Post hoc subgroup analyses in meta-analyses are prone to false-positive findings due to multiple testing, as highlighted by recent methodological critiques.⁴

Finally, the absence of patient-reported outcomes (e.g., dizziness, falls) represents a critical gap. Orthostatic hypertension is often asymptomatic, but its clinical relevance hinges on symptom burden and quality of life. Excluding these endpoints prevents a balanced assessment of treatment risks and benefits, contrary to evolving standards for patient-centered outcomes research.⁵

In conclusion, while this meta-analysis advances our understanding of orthostatic hypertension, future studies should adopt standardized definitions, prioritize clinical outcomes, and incorporate patient-reported measures.

References
1. Riley RD, Lambert PC, Abo-Zaid G. Meta-analysis of individual participant data: rationale, conduct, and reporting. BMJ 2010;340:c221.
2. Ricci F, Fedorowski A, Radico F, et al. Diagnostic criteria for orthostatic hypertension: A consensus statement. J Hypertens 2022;40(5):811-8.
3. Frewen J, Savva GM, Boyle G, et al. Orthostatic hypotension and orthostatic hypertension predict incident dementia among older adults: The Irish Longitudinal Study on Ageing. J Alzheimers Dis 2021;81(2):603-13.
4. Sun X, Briel M, Walter SD, et al. Credibility of claims of subgroup effects in randomised controlled trials: systematic review. BMJ 2010;340:c117.
5. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA 2017;318(2):197-8.

Dear Editor
The thoughtful opinion piece by Higginson et al rightly underscores the urgent need to address inequality in access to hospice and end-of-life care. Central to this effort must be a deliberate focus on those living at the margins—people who are often most excluded from current systems of care, including individuals experiencing homelessness, ethnically diverse groups (those who are not White British), people with disabilities, and those living in socioeconomic deprivation.

Persistent structural inequities mean that these populations face significant barriers—ranging from cultural and institutional to logistical and financial—that limit their access to compassionate, timely, and appropriate end-of-life care. These are not peripheral issues; they are central challenges that reflect the broader failures of our healthcare systems to provide universal, dignified care at life’s end.

Critically, any work done to improve hospice and palliative services that does not focus on those at the margins risks deepening inequality.1 Without intentional focus, efforts to improve services may disproportionately benefit those who already have the best access and outcomes—leaving behind those who are already getting the least and the worst.

Crucially, by prioritising the needs of those at the margins, we can develop innovative, inclusive, and scalable solutions that ultimately improve care for everyone. The most effective, sustainable models of hospice and palliative care will be those built with the most vulnerable in mind—not as an afterthought, but as the starting point. When care systems are designed to work for people with the greatest needs, they inherently become more flexible, responsive, and equitable for all.

Any work to reform hospice and palliative care must therefore place the lived realities of marginalised communities at the forefront.

1. Bajwah S et al. Equal but inequitable: response of specialist palliative care and hospice services to people from ethnic minority groups with COVID-19-an observational study (CovPall). BMJ Supportive & Palliative Care 2021

Dear Editor

The Sonolysis in Prevention of Brain Infarctions During Internal Carotid Endarterectomy (SONOBIRDIE) trial is a well-conducted, multicentre, randomised controlled study evaluating the efficacy and safety of sonolysis, a low-intensity pulsed wave ultrasound technique in carotid endarterectomy (CEA). The trial investigates a neurovascular protection strategy aimed at reducing perioperative cerebral events. The primary endpoint was a composite of ischaemic stroke, transient ischaemic attack (TIA), and death within 30 days, while secondary outcomes included the appearance of new ischaemic lesions on brain magnetic resonance imaging (MRI), and the key safety endpoint was the incidence of intracranial bleeding.

The trial is methodologically strong, with a sham-controlled design, appropriate blinding (except for the sonographer), adequate statistical power, and clinically meaningful imaging and composite outcomes. The observed absolute risk reduction of 5.5% in the composite outcome (P < 0.001) is notable and suggests that sonolysis may offer significant benefit in improving perioperative outcomes following CEA.

However, several important limitations should be acknowledged. First, although blinding was maintained across most of the trial team, the sonographers were unblinded, which, while practically unavoidable, introduces the potential for bias. Second, the trial employed a variety of commercially available transcranial Doppler ultrasound machines without a unified protocol for sonolysis delivery across centres. This lack of standardisation may have introduced variability in insonation parameters, operator technique, and therapeutic dose delivery, potentially affecting reproducibility and limiting the translation of these findings into routine practice. Standardised, purpose-designed sonolysis devices would be beneficial in future studies.

In addition, given the study’s five-year duration, the natural evolution of surgical and ultrasound technique over time, along with increasing operator experience, may have contributed to improved outcomes. A year-by-year analysis of recruitment and complication rates by centre would be helpful to identify potential learning curve effects. The study population also included a clinically heterogeneous mix of symptomatic (45%) and asymptomatic (55%) carotid stenosis patients. These cohorts differ significantly in stroke risk, treatment indications, and guideline recommendations. Stratified reporting or subgroup analysis would clarify whether sonolysis confers equal benefit across these groups—particularly important given the ongoing debate over intervention in asymptomatic carotid disease.

Generalisation of the findings may also be limited by the study’s setting. All participating centres were based in Central Europe, and while the intervention demonstrated efficacy within this context, broader applicability to more diverse health systems remains uncertain. For instance, despite the observed relative risk reduction, both the composite outcome and the 30-day rate of stroke or TIA were higher than those reported in the 2024 UK National Vascular Registry1. Moreover, the finding that female sex independently increased the risk of adverse outcomes (Odds Ratio 2.0) is an important observation that aligns with previous reports but remains underexplored in this study. Further research should investigate sex-based differences in procedural outcomes more thoroughly.

The early termination of the trial following interim analysis for efficacy, while justified, raises concerns about potential overestimation of treatment effect and reduced statistical power for evaluating secondary and safety outcomes. Furthermore, the cost implications of implementing sonolysis were not addressed. A formal health economic analysis, especially within resource-constrained systems such as the NHS, would be essential to evaluate the feasibility and sustainability for wider adoption of this procedure.

In conclusion, the SONOBIRDIE trial marks an important step toward integrating therapeutic ultrasound into vascular practice. The results are promising, particularly for improving perioperative outcomes in patients with asymptomatic carotid stenosis. However, several key questions remain regarding long-term effectiveness, centre-level variability, cost-effectiveness, and generalisability. We encourage the authors to address these issues in future analyses or correspondence to support informed clinical implementation.

References
1. VASGBI. National Vascular Registry Report 2024: Summary for Anaesthetists. VASGBI, https://vasgbi.com/research-audit/nvr-summary-2024/ (Accessed 24 March 2025).