The battle between proponents and opponents of breast screening has
reached a well entrenched stalemate. (1). A new randomised trial which
could confirm or refute breast screening benefits is not realistically
feasible.
The women's views in this study offers an elegant way forward. (2).
We need to untangle the issue of over- treatment from over- diagnosis.
Rather than concentrating on over- diagnosis, the optio...
The battle between proponents and opponents of breast screening has
reached a well entrenched stalemate. (1). A new randomised trial which
could confirm or refute breast screening benefits is not realistically
feasible.
The women's views in this study offers an elegant way forward. (2).
We need to untangle the issue of over- treatment from over- diagnosis.
Rather than concentrating on over- diagnosis, the option of active
surveillance for low grade lesions needs to be explored.
The use of PSA screening in men coupled with active surveillance for
low risk prostate cancer suggests that this approach is clinically
feasible. (3). Non- prostate clinicians should note that active
surveillance is different from wait &watch policy. Active surveillance
implies close clinical observation followed by active curative treatment
when there is progression of lesions (low grade cancer or DCIS) whereas a
wait &watch policy implies symptom directed, often palliative, management
of cancer.
A feasibility study followed by a large scale randomised study of
active surveillance for 'low- risk' screen detected lesions (DCIS or
cancer) is urgently needed. Cancer Research UK should use its considerable
resources to kick start an active surveillance trial for women.
References
1. Independent UK Panel on Breast Cancer Screening, The benefits and
harms of breast cancer screening: an independent review. Lancet
2012;380:1778-86
2. Waller J, Douglas E, Whitaker KL, Wardle J. Women's responses to
information about overdiagnosis in the UK breast screening programme: a
qualitive study. BMJ Open 22 Apr 2013, doi:10.1136/bmjopen-2013-002703.
3. NICE clinical guideline 58. Prostate cancer: diagnosis and
treatment. 2008. http://www.nice.org.uk/CG058 (accessed 29 April 2013).
In Brurberg et al, BMJ 7 February 2014 "Case definitions for chronic
fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review"
the authors make the following comment:
"Psychological treatments are often helpful also for clear-cut
somatic disorders. Unfortunately, patient groups and researchers with
vested interests in the belief that ME is a distinct somatic disease seem
unwilling to leave the p...
In Brurberg et al, BMJ 7 February 2014 "Case definitions for chronic
fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review"
the authors make the following comment:
"Psychological treatments are often helpful also for clear-cut
somatic disorders. Unfortunately, patient groups and researchers with
vested interests in the belief that ME is a distinct somatic disease seem
unwilling to leave the position that ME is an organic disease only. This
position has damaged the research and practice for patients suffering from
CFS/ME."[1]
These are odd comments to make by authors who are so heavily involved
in the CBT/GET model for this condition themselves.
As one of those patient groups believing in an organic cause for ME
we feel we need to comment on this.
Patients have never objected to psychological treatments in the way
they are used for clear-cut somatic disorders. Patient organisations have
objected to the types of psychological treatments offered to ME patients.
For example, the so called PACE trial that the authors refer to in
this article state in their CBT manuals for therapists
"Participants are encouraged to see symptoms as temporary and
reversible and not as signs of harm or evidence of fixed disease
pathology. In this way it is anticipated that they will gain more control
of their lives, as they, and not their symptoms, dictate what they do".[2]
Is this not this clear evidence of a group of researchers having a
position of ME/CFS as somatoform disease only?
How does this compare to the supportive psychological treatments
offered to clear cut somatic conditions?
Dr Ian Gibson's report on ME from 2006 had the following observation
[3] -
"There have been numerous cases where advisors to the DWP have also
had consultancy roles in medical insurance companies. ........ Given the
vested interest private medical insurance companies have in ensuring
CFS/ME remain classified as a psychosocial illness there is blatant
conflict of interest here. The Group find this to be an area for serious
concern and recommends a full investigation of this possibility by the
appropriate standards body. It may even be that assessment by a medical
'expert' in a field of high controversy requires a different methodology
of benefit assessment"
At the 8th Invest in ME International ME Conference 2013 [4] Dr Clare
Gerada, chair of RCGPs, stated that patients usually know their illness
better than doctors.
Patients are living with this disease and it would be odd if they did
not question research that is at odds with their lived experience.
We are sure cancer patients would find it unacceptable too if all
they were offered were psychological assurances that there was nothing
organically wrong with them and research was done on a broad spectrum of
cancer patients without any attempt to select homogeneous groups of
patients to find the cause and cure for the many different forms of
cancer.
Invest in ME is a charity run by volunteer patients and carers. We
have organised eight international ME/CFS biomedical research conferences
so far and this year we shall show more biomedical research at our ninth.
[5]
The BMJ sent a representative to attend our conference three years
ago and they encouraged us to initiate good quality clinical trials.
We can now inform the BMJ and anyone else interested in the organic
origins of ME/CFS that we have since initiated a gut microbiota project
involving ME/CFS patients at IFR/UEA, Norwich.
We have also raised funds for a clinical trial to treat ME/CFS
patients with rituximab at UCL following on from the promising results in
Haukeland University, Bergen, Norway.
We have sent an invitation to the BMJ to attend again this year to
see the progress that has been made.
It would be of great benefit to the patient doctor relationship if
doctors and other healthcare professionals came to listen and learn about
these exciting new developments into ME/CFS that will be on display in
London on May 30th.
Far from damaging the research and practice for patients suffering
from ME it is actually patients who removing the myths about this disease
References
1. Kjetil Gundro Brurberg, Marita Sporst?l F?nhus, Lillebeth Larun,
Signe Flottorp, Kirsti Malterud. Case definitions for chronic fatigue
syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review. BMJ Open
2014;4:e003973
This is excellent work, and something most of us, i would like to
think,know for a very long time!
Time pressures is the single most important factor, aside from lack
of knowledge and skills, that results in acts of commission or omission,
sometimes with harm ensuing. Something akin to "system error"
A GMC backed study recently suggested, due to time pressures, GPs
find it difficult to achieve the requ...
This is excellent work, and something most of us, i would like to
think,know for a very long time!
Time pressures is the single most important factor, aside from lack
of knowledge and skills, that results in acts of commission or omission,
sometimes with harm ensuing. Something akin to "system error"
A GMC backed study recently suggested, due to time pressures, GPs
find it difficult to achieve the requisite amount of CPD. And then there
was the major study on prescribing errors in primary care recently and an
important theme there was time pressures disabling GPs from getting it
right all the time. The RCGP, unless i am wrong, has called for extension
of the consultation time from 10 to 15minutes- i agree.
Can you imagine, comparing us to other professionals like Lawyers or
others, which reasonable man on the Clapham Omnibus would consider 10
minutes as anywhere satisfactory for a proper holistic safe consultation?
When patients are told they only have 10 minutes they are often shocked to
hear this.
Whereas one can appreciate that to get through the workload in ones
day,short consultations time are the only way round that, i would argue
the end does not justify the means however way you look at it.
Please note corrections to: A qualitative interview study: patient
accounts of medication use in early rheumatoid arthritis from symptom
onset to early postdiagnosis Anne Townsend, Catherine L Backman, Paul
Adam, Linda C Li
BMJ Open 2013;3:2 e002164 doi:10.1136/bmjopen-2012-002164
Table 1
a) Name: Dodi
Heading: Referral wait time to see a rheumatologist
Please note corrections to: A qualitative interview study: patient
accounts of medication use in early rheumatoid arthritis from symptom
onset to early postdiagnosis Anne Townsend, Catherine L Backman, Paul
Adam, Linda C Li
BMJ Open 2013;3:2 e002164 doi:10.1136/bmjopen-2012-002164
Table 1
a) Name: Dodi
Heading: Referral wait time to see a rheumatologist
'10 months' - This should read: '5 months'
b) Name: Jackie
Heading: Symptom onset to seeing Rx
'8 months' - This should read '2-3 months'
Heading: Seeking medical help for symptoms leading to a diagnosis/RA
test
'3 months' - This should read '2 months'
Heading: Referral wait time to see a rheumatologist
Dr. Pantzaris and colleagues (1) have recently performed a study on a
dietary intervention consisting of omga-3, omega-6 and vitamin A and -E in
various formulations in relapsing-remitting multiple sclerosis (RR-MS).
The authors suggested that a special combination of omega-3, omega-6 and
fat soluble vitamins could have profound effects on magnetic resonance
(MR) disease activity and disease progression. The main problem i...
Dr. Pantzaris and colleagues (1) have recently performed a study on a
dietary intervention consisting of omga-3, omega-6 and vitamin A and -E in
various formulations in relapsing-remitting multiple sclerosis (RR-MS).
The authors suggested that a special combination of omega-3, omega-6 and
fat soluble vitamins could have profound effects on magnetic resonance
(MR) disease activity and disease progression. The main problem in
intervention studies, where different compounds and interventions are
combined, is to determine which substance actually had a therapeutic
effect. There have been a number of both randomised controlled trials and
cohort studies published on dietary intervention in MS, which could have
helped to explain the findings in this study (for two excellent reviews,
see Geldern et al. (2) and Farinotti et al (3)). Unfortunately, these
studies have not been cited or discussed in the article. We think these
newly published data should be taken into account when interpreting their
results, as this will be of great importance for future larger randomised
controlled clinical trials.
As one of their findings, the authors suggest that omega-3
intervention, in the form of eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), could have therapeutic effects in MS. Although
omega-3 has a theoretic anti-inflammatory effect, recently performed RCTs
have not detected any positive effects on relapse-rate (4, 5) or MRI
activity (6). Further, experimental studies in different animal models for
MS have indicated conflicting results, with most studies actually
reporting a negative effect of omega-3 intervention (7). Thus, there seems
to be little rationale for choosing EPA and DHA as interventional
substances. The fact that the authors did not detect any positive effect
in treatment arm A, where these substances were given, further suggests
that EPA and DHA did not have any treatment effect in this study either.
The authors also gave the patients in two of the experimental groups
omega-6 fatty acids in the form of gamma-linoleic acid (GLA) and linoleic
acid. Some studies have indicated a possibly reduced relapse severity and
lower increase in disability in those receiving GLA than placebo (8), but
the results are difficult to interpret because of lacking information on
dropouts and patient characteristics. One recently published Cochrane
review, based on all published studies on omega-3 and omega-6
supplementation, concluded that PUFA supplementation seemed to have no
effect on disease progression (3). Although it is possible that the omega-
6 supplementation given to the MS-patients in two of the treatment groups
could have had a beneficial effect on MRI disease activity, this seems
less likely, as both group A and B also received the same dosage of omega-
6 supplementation.
Recently performed cohort-studies indicate that both vitamin A and E
could have important disease modifying effects in MS (9, 10). Further,
both vitamins have biological properties and have demonstrated positive
effects in animal models for MS, which make them interesting candidates
for future intervention studies (11). In one cohort study, where patients
were followed for two years, we found that each 1 ?mol/L increase in serum
-retinol reduced the odds ratio for new T1 gadolinium enhanced lesions by
49%, new T2 lesions by 42%, and combined unique activity by 46% in
simultaneous MRI scans (9). We were also able to control for serum-levels
of EPA, DHA and 25-hydroxyvitamin D, and found that they did not affect
this association. Also higher serum levels of Retinol Binding Protein (a
surrogate marker for vitamin A) has recently been demonstrated to be
associated with decreased MS risk (OR=0.38) (12). In Pantzaris' and
colleagues study (1), vitamin A was given to the patients in intervention
group A and B, but the amount was rather moderate (0.6 mg), which is below
the recommended dietary allowance for men and women of 0.9 and 0.7 mg,
respectively.
For vitamin E, we have demonstrated that during interferon beta (IFNB)
treatment, each 10 ?mol/L increase in alpha-tocopherol reduced the odds
ratio for simultaneous new T2 lesions by 36.8%, and for combined unique
activity by 35.4% (10). As for vitamin A, we were also in this study able
to control for serum-levels of EPA, DHA and 25-hydroxyvitamin D, without
detecting any interaction. Since the patients in group B received both
vitamin A and high dose vitamin E, this combination seems to be the most
plausible explanation for the positive effect in this study, and not EPA
and DHA, which were also given to the treatment arm where no effect was
detected.
The authors of the present study reported a dropout rate of 49%,
making it difficult to draw firm conclusions about their results. As most
patients discontinued because of unpleasant taste and smell of the
interventional treatment with fatty oils, we would suggest that future
studies could primarily aim at detecting a possible protective effect of
vitamin A and E treatment. This would probably greatly influence the
compliance in future studies. The biological rationale for choosing these
substances are stronger than for the PUFA-supplementation, which based on
what we know from previous studies, probably have no beneficial effects in
MS (3).
References:
1 Pantzaris MC, Loukaides GN, Ntzani EE, Patrikios IS. A novel oral
nutraceutical formula of omega-3 and omega-6 fatty acids with vitamins
(PLP10) in relapsing remitting multiple sclerosis: a randomised, double-
blind, placebo-controlled proof-of-concept clinical trial. BMJ Open. 2013;
3 (4).
2 Geldern G, Mowry EM. The influence of nutitional factors on the
prognosis of multiple sclerosis. Nature Reviews Neurology. 2012; 8, 678-
689
3 Farinotti M, Vacchi L, Simi S, Di Pietrantonj C, Brait L, Filippini
G.Dietary interventions for multiple sclerosis. Cochrane Database Syst
Rev. 2012; 12: CD004192.
4 Bates D, Cartlidge NE, French JM, et al. A double-blind controlled
trial of long chain n-3 polyunsaturated fatty acids in the treatment of
multiple sclerosis. J Neurol Neurosurg Psychiatry. 1989; 52 : 18-22.
5 Weinstock-Guttman B, Baier M, Park Y, et al. Low fat dietary
intervention with omega-3 fatty acid supplementation in multiple sclerosis
patients. Prostaglandins Leukot Essent Fatty Acids. 2005; 73: 397-404.
7 Wergeland S, Torkildsen O, Myhr KM, Bo L. Polyunsatturated fatty
acids in multiple sclerosis therapy. Acta Neuroligca Scandinavica Suppl.
2012: 195; 70-75.
8 Dworkin, R. H., Bates, D., Millar, J. H. D. & Paty, D. W.
Linoleic acid and multiple sclerosis: a reanalysis of three double-blind
trials. Neurology. 1984; 34, 1441-1445.
9 Loken-Amsrud KI, Myhr KM, Bakke SJ, Beiske AG, Bjerve KS, Bjornar?
BT, Hovdal H, Lilleaas F, Midgard R, Pedersen T, ?altyt? Benth J,
Torkildsen O, Wergeland S, Holmoy T. Retinol levels are associated with
MRI disease activity in multiple sclerosis. Multiple Sclerosis. . 2013;
19: 451-457.
10 Loken-Amsrud KI, Myhr KM, Bakke SJ, Beiske AG, Bjerve KS, Bjornar?
BT, Hovdal H, Lille?s F, Midgard R, Pedersen T, ?altyt? Benth J,
Torkildsen O, Wergeland S, Holmoy T. Alpha-tocopherol levels are
associated with MRI outcomes in multiple sclerosis. PloS one.
2013;8:e54417.
11 Torkildsen O, Loken-Amsrud KI, Wergeland S, Myhr KM, Holmoy T. Fat
soluble vitamins as modulators of disease activity in multiple sclerosis.
Acta Neurologica Scandinavica Suppl. 2013; 196: 16-23.
12 Salzer J, Hallmans G, Nystrom M, Stenlund H, Wadell G, Sundstrom
P. Vitamin A and systemic inflammation as protective factors in multiple
sclerosis. Multiple Sclerosis. 2013; Jan 18. [Epub ahead of print].
We appreciate Dr. Goudsmit's interest in our paper (1) and thank her
for pointing out a potential confusion. The revised 2009 criteria could
have been included in the list of list of existing case definitions had we
identified them. Nonetheless, our main objective was to demonstrate that
it is possible to validate diagnostic studies, even in the absence of a
reference standard and to summarize existing validation studies....
We appreciate Dr. Goudsmit's interest in our paper (1) and thank her
for pointing out a potential confusion. The revised 2009 criteria could
have been included in the list of list of existing case definitions had we
identified them. Nonetheless, our main objective was to demonstrate that
it is possible to validate diagnostic studies, even in the absence of a
reference standard and to summarize existing validation studies. We do not
claim that existing case definitions are unable to distinguish between sub
-populations, but we cannot reliably reach such conclusions based on the
current evidence base. If we have missed important validation studies,
conducted in accordance with our inclusion criteria and consistent with
one of the three validation models we outline in our review, we would be
happy to receive the references.
1. Brurberg KG, Fonhus MS, Larun L, Flottorp S, Malterud K. Case
definitions for chronic fatigue syndrome/myalgic encephalomyelitis
(CFS/ME): a systematic review. BMJ Open 2014;4:e003973 doi:10.1136/bmjopen
-2013-003973
I acknowledge the authors attempts to correct for confounders such as
placenta pravia and breech in this interesting paper, but also think that
the significant known confounding effect of maternal age (some references
below) and effects on mode of delivery should also have been addressed.
Am J Obstet Gynecol. 1987 Feb;156(2):305-8.
Maternal age and primary cesarean section rates: a multivariate analysis.
Martel M,...
I acknowledge the authors attempts to correct for confounders such as
placenta pravia and breech in this interesting paper, but also think that
the significant known confounding effect of maternal age (some references
below) and effects on mode of delivery should also have been addressed.
Am J Obstet Gynecol. 1987 Feb;156(2):305-8.
Maternal age and primary cesarean section rates: a multivariate analysis.
Martel M, Wacholder S, Lippman A, Brohan J, Hamilton E.
Bell, Jacqueline S., et al. "Do obstetric complications explain high
caesarean section rates among women over 30? A retrospective analysis."
BMJ: British Medical Journal 322.7291 (2001): 894.
We have read Angela P. Kennedys response on our review (1) with
interest. Some of the issues she rises are covered by our previous
comments/responses. Moreover, we disagree with the statement that problems
of validity remain no matter how much "empirical" research is done.
Research regarding etiology, prognosis and therapy is important to
increase our knowledge about CFS/ME, this also implies a need to validate
and compa...
We have read Angela P. Kennedys response on our review (1) with
interest. Some of the issues she rises are covered by our previous
comments/responses. Moreover, we disagree with the statement that problems
of validity remain no matter how much "empirical" research is done.
Research regarding etiology, prognosis and therapy is important to
increase our knowledge about CFS/ME, this also implies a need to validate
and compare various diagnostic criteria.
1. Brurberg KG, Fonhus MS, Larun L, Flottorp S, Malterud K. Case
definitions for chronic fatigue syndrome/myalgic encephalomyelitis
(CFS/ME): a systematic review. BMJ Open 2014;4:e003973 doi:10.1136/bmjopen
-2013-003973
I think you very much for your comment on the article. In response
to your comment I have now re-analysed the pre-labour caesarean section
rates according to age group, ie for women under the age of 30 and women
over 29.
The separate results for these two age groups showed exactly the same
pattern as for the groups combined. For example, the caesarean section
rate for women over 29 years of age increased by...
I think you very much for your comment on the article. In response
to your comment I have now re-analysed the pre-labour caesarean section
rates according to age group, ie for women under the age of 30 and women
over 29.
The separate results for these two age groups showed exactly the same
pattern as for the groups combined. For example, the caesarean section
rate for women over 29 years of age increased by 5.4% annually (CI=3-8%)
for private patients, but was stable at 1.4% for public patients.
Similarly, for women under 30 years of age, caesarean sections increased
by 6% annually (CI=1-12) for private patients, but were again stable at
0.5% for public patients.
We therefore believe that there is minimal, if any, confounding by
age as the effect exist for both older and younger women.
I would like to thank the authors for replying to my e-letter (1).
However, I do not believe they have justified their claim. They say:
"Where we claim that evidence indicates that the side effects of cognitive
behavioural treatment or graded exercise therapy are negligible, it is
with references to other systematic reviews and trials." Firstly, it
should be pointed out that important harms-related data is often derived...
I would like to thank the authors for replying to my e-letter (1).
However, I do not believe they have justified their claim. They say:
"Where we claim that evidence indicates that the side effects of cognitive
behavioural treatment or graded exercise therapy are negligible, it is
with references to other systematic reviews and trials." Firstly, it
should be pointed out that important harms-related data is often derived
outside of clinical trials (2).
Secondly, I do not believe systematic reviews state what they claim.
For example, a systematic review by Chambers and colleagues (3)
concluded, "There is limited evidence about adverse effects associated
with behavioural interventions. Withdrawals from treatment in RCTs suggest
that there may be an issue but the evidence is often difficult to
interpret because of poor reporting."
One of the authors (Larun Lillebeth) previously published a Cochrane
collaboration systematic review of trials of graded exercise therapy which
found that no data on adverse effects had been reported (4). They
concluded: "... studies of higher quality are needed that involve
different patient groups and settings, and that measure additional
outcomes such as adverse effects ...".
As I highlighted previously (2), the Cochrane Collaboration:
"similarly reviewed RCTs of CBT for CFS in 2000 (5) and performed an
update in 2008 (6). Out of 14 separate RCTs examined, only one had any
data to assess patient acceptability and none of the studies had good
quality data related to adverse effects. In the "Selective outcome
reporting" subsection of "Risk of bias in included studies", the
Collaboration authors wrote (6): "Whilst Lloyd 1993 collected data
concerning the adverse effects of DLE injection, data referring to adverse
effects of psychological treatment was not systematically presented by any
study." Drop-out rates averaged 16% across studies but definitions for
what constituted "drop-outs" varied and reasons for attrition were not
detailed; a third of the studies had drop-out rates over 20%. The authors
finished by asserting that future studies should incorporate data on
adverse effects and acceptability among other outcome measures."
Due to this poor reporting of harms in trials, among other reasons, I
do not accept we have sufficient evidence for the authors to claim "the
side effects of cognitive behavioural treatment or graded exercise therapy
are negligible."
References:
1. Brurberg Kjetil G., Fonhus Marita S., Larun Lillebeth, Flottorp
Signe, Malterud Kirsti. Re:High rates of deterioration following graded
exercise therapy and cognitive behavioural therapy have been reported in
patient surveys
http://bmjopen.bmj.com/content/4/2/e003973.full/reply#bmjopen_el_7759
2. Kindlon T. Reporting of Harms Associated with Graded Exercise
Therapy and Cognitive Behavioural Therapy in Myalgic
Encephalomyelitis/Chronic Fatigue Syndrome. Bulletin of the IACFS/ME.
2011;19(2):59-111.
http://iacfsme.org/BULLETINFALL2011/Fall2011KindlonHarmsPaperABSTRACT/tabid/501/Default.aspx
(Accessed: February 7, 2014)
3. Chambers D, Bagnall AM, Hempel S, Forbes C. Interventions for the
treatment, management and rehabilitation of patients with chronic fatigue
syndrome/myalgic encephalomyelitis: an updated systematic review. J R Soc
Med. 2006;99:506-20. Review.
4. Larun L, McGuire H, Edmonds M, Odgaard-Jensen J, Price JR.
Exercise therapy for chronic fatigue syndrome. Cochrane Database of
Systematic Reviews 2004, Issue 3. Art. No.: CD003200. DOI:
10.1002/14651858.CD003200.pub2
5. Price JR, Couper J. Cognitive behaviour therapy for adults with
chronic fatigue syndrome. Cochrane Database Syst Rev 2000;(2):CD001027
[review].
6. Price JR, Mitchell E, Tidy E, Hunot V. Cognitive behaviour therapy
for chronic fatigue syndrome in adults. Cochrane Database Syst Rev.
2008;(3):CD001027.
Conflict of Interest:
I am the Information Officer and Assistant Chairperson of the Irish ME/CFS Association. All my work for the Association is unpaid.
The battle between proponents and opponents of breast screening has reached a well entrenched stalemate. (1). A new randomised trial which could confirm or refute breast screening benefits is not realistically feasible.
The women's views in this study offers an elegant way forward. (2). We need to untangle the issue of over- treatment from over- diagnosis. Rather than concentrating on over- diagnosis, the optio...
In Brurberg et al, BMJ 7 February 2014 "Case definitions for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review" the authors make the following comment:
"Psychological treatments are often helpful also for clear-cut somatic disorders. Unfortunately, patient groups and researchers with vested interests in the belief that ME is a distinct somatic disease seem unwilling to leave the p...
This is excellent work, and something most of us, i would like to think,know for a very long time!
Time pressures is the single most important factor, aside from lack of knowledge and skills, that results in acts of commission or omission, sometimes with harm ensuing. Something akin to "system error"
A GMC backed study recently suggested, due to time pressures, GPs find it difficult to achieve the requ...
Please note corrections to: A qualitative interview study: patient accounts of medication use in early rheumatoid arthritis from symptom onset to early postdiagnosis Anne Townsend, Catherine L Backman, Paul Adam, Linda C Li BMJ Open 2013;3:2 e002164 doi:10.1136/bmjopen-2012-002164
Table 1
a) Name: Dodi
Heading: Referral wait time to see a rheumatologist
'10 months' - This should read...
Dr. Pantzaris and colleagues (1) have recently performed a study on a dietary intervention consisting of omga-3, omega-6 and vitamin A and -E in various formulations in relapsing-remitting multiple sclerosis (RR-MS). The authors suggested that a special combination of omega-3, omega-6 and fat soluble vitamins could have profound effects on magnetic resonance (MR) disease activity and disease progression. The main problem i...
We appreciate Dr. Goudsmit's interest in our paper (1) and thank her for pointing out a potential confusion. The revised 2009 criteria could have been included in the list of list of existing case definitions had we identified them. Nonetheless, our main objective was to demonstrate that it is possible to validate diagnostic studies, even in the absence of a reference standard and to summarize existing validation studies....
I acknowledge the authors attempts to correct for confounders such as placenta pravia and breech in this interesting paper, but also think that the significant known confounding effect of maternal age (some references below) and effects on mode of delivery should also have been addressed.
Am J Obstet Gynecol. 1987 Feb;156(2):305-8. Maternal age and primary cesarean section rates: a multivariate analysis. Martel M,...
We have read Angela P. Kennedys response on our review (1) with interest. Some of the issues she rises are covered by our previous comments/responses. Moreover, we disagree with the statement that problems of validity remain no matter how much "empirical" research is done. Research regarding etiology, prognosis and therapy is important to increase our knowledge about CFS/ME, this also implies a need to validate and compa...
I think you very much for your comment on the article. In response to your comment I have now re-analysed the pre-labour caesarean section rates according to age group, ie for women under the age of 30 and women over 29.
The separate results for these two age groups showed exactly the same pattern as for the groups combined. For example, the caesarean section rate for women over 29 years of age increased by...
I would like to thank the authors for replying to my e-letter (1). However, I do not believe they have justified their claim. They say: "Where we claim that evidence indicates that the side effects of cognitive behavioural treatment or graded exercise therapy are negligible, it is with references to other systematic reviews and trials." Firstly, it should be pointed out that important harms-related data is often derived...
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