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Displaying 1-10 letters out of 583 published

  1. Correction

    On Page 4, paragraph 2, line 5: the word 'concave' should be changed to 'convex'. We apologize for any inconvenience caused by this omission.

    Conflict of Interest:

    None

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  2. Response to: Evaluation of a minor eye condition service delivered by community optometrists

    Dear Sir It is with great interest that we read your article evaluating a Minor Eye Condition Scheme (MECS) in the Lambeth and Lewisham area1. We note that 2123 patients were seen in this scheme, of which 1747 were seen and maintained within the community setting (82.3%). This was despite the fact that predominantly lubricants and chloramphenicol/fuscidic acid was prescribed. No steroids or antivirals were prescribed. It is likely therefore, that the first-line treatment offered by most GPs of lubricants and/or chloramphenicol would have led to resolution of these symptoms. It is therefore unlikely that these patients would have been referred to secondary care services in the first instance. We note that first-visit attendances to hospital eye services (HES) from GPs dropped by 26.8% over the study period. To understand if the number of total referrals to HES were reduced it would be useful to have the number of referrals from both GPs and the MCES scheme to the HES as well as from GPs to MECS. If this is higher than the comparator it would suggest an increase in referrals for conditions that do not require specialist intervention. This would indicate a failure of the scheme. Further, we note that approximately 1 in 5 (18.9%) patients referred into the scheme were referred to secondary care. Half of these referrals were for urgent or emergency referrals. This would equate to approximately 1 in 10 patients potentially increasing their journey to specialist intervention, if referred from GPs into this scheme. One of the inclusion criteria to this study was sudden loss of vision. Normally, the cause for painless loss of vision is vascular. Patients often need medical assessment with BP and blood tests. In the case of Giant Cell Arteritis urgent blood tests and commencement of oral steroid are required. In cases of amourosis fugax calculation of the stroke risk and liaising with the local stroke services is indicated. Unless these tests and services are linked with the community scheme this will prolong the patient pathway and increase costs. Out of the 13 practices included in the study, 22.8% of patients (483) were seen by 1 practice alone and 2 practices accounted for 39.2% of all the patients seen under the MECS scheme. This significantly skews the results and is not representative of the entire study practice or optometrist population. It would not be possible to generalise or conclude that this demonstrates the clinical effectiveness of the MECS scheme overall. The data shows that Ophthalmologists judged approximately 11% of the referrals to the HES via the MECS scheme unnecessary. This would be evidence against the clinical and cost-effectiveness of the MECS scheme. Whilst the data represented suggests that this scheme is clinically effective the cost-effectiveness of this scheme is unclear. The background to the development of these schemes has been to reduce the burden of non- sight threatening eye disease in secondary care and save money for local CCGs and the NHS. The clinical effectiveness of over-referral or unnecessary referral is not in doubt. However, the cost is unnecessary and savings could be made.

    We would suggest that prior to implementing MECS schemes we would need to determine the total cost saving taking into account the points that we have raised. We agree with the authors that MECS schemes must enhance clinical and decision-making skills of optometrists. Currently, the MECS accreditation structure does not account for these two fundamental parameters in its assessments. This study had high-levels of ophthalmologists support with mentoring and referral feedback which would indicate a constant improvement in the optometry referrals from MECS during the study period. We feel that this is another reason for the clinical effectiveness of this study. Unfortunately, LOCSU2 do not explicitly require this as part of implementing a MECS scheme elsewhere. The variation in referral pattern of between 5-30% in this study, despite no differences in case-mix, may be attributable to variations in clinical and decision-making skills which are not taught/assessed in the MECS scheme. References 1. Konstantakopoulou E, Edgar DF, Harper RA, et al. Evaluation of a minor eye conditions scheme delivered by community optometrists. BMJ Open 2016;6:e011832. doi:10.1136/bmjopen-2016- 011832 2. Accessed on 22/11/2016 at: http://www.locsu.co.uk/community-services- pathways/primary-eyecare-assessment-and-referral-pears/

    Conflict of Interest:

    None declared

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  3. Patient and healthcare perspectives on the importance and efficacy of addressing spiritual issues within an interdisciplinary bone marrow transplant clinic: a qualitative study

    This study addresses an important gap in the literature regarding the assessment of spiritual issues for patients undergoing a bone marrow transplant. Despite knowing that spiritual well-being is an important component of quality of life, it remains under addressed by healthcare professionals. In this study, both sides of participants, patients and clinicians, agreed that addressing spiritual issues was an important aspect of comprehensive care. The article mentioned barriers to addressing those concerns. On one part, spirituality is a challenging concept to grasp, as it is difficult to define and it varies from one person to another. On the other hand, healthcare providers report a lack of competencies and confidence in addressing spiritual issues.

    Although spirituality might not fall within the scope of practice of a specific profession, I consider nurses to be in a central position to care for the patients as a whole. Of all healthcare professionals, nurses are the most present at the bedside, caring for patients and families around the clock. They are not only looking at the physical aspect of the diseases, but also at how the patient is coping with the illness and the overall impact it has on their life.

    Because spirituality is not a formal aspect of Western medicine, it is not automatically part of the curriculum in North America. Puchalski (2006) reported the results of a study showing that patients' trust toward healthcare professionals increases when spiritual issues are addressed. This demonstrates the positive impacts it has not only on the patients' well-being, but also on the collaborative partnership developed between patients and their healthcare provider. In order to address patients' spiritual issues adequately, nurses need to be familiar with the topic and the need for more training is undeniable.

    Although the article mention the beneficial aspect of having a spiritual-care professional as part of the interdisciplinary team, it is not a realistic solution for all. Here in Quebec, it would be a luxury to have such a professional, in the reality of the repetitive budget cuts that the healthcare system is facing. This is one of the reasons why I emphasize with the need for other professionals, such as nurses, to expand their competencies and to fill the gap.

    I really appreciated the specific clinical time points for addressing spiritual issues that were suggested. Both specific time points (diagnosis, post-transplant and survivorship) as well as clinical indicators (prognostic change, existential crisis and physical symptomology) are pertinent time for assessing spiritual issues. Both sets of participants also emphasized the need for an integrated and routine approach. I believe that this can serve as a starting point for developing specific tools that nurses could use to assess spirituality as part of their global assessment.

    In regards to the sample of participants used, out of the seven patient participants, none of the them was 'neither religious nor spiritual'. Because of the convenience sample used, it might be an atypical representation of the population and provide a biased view on spirituality. One of the conclusion drawn from that research is that there is a desire amongst patients to have their spiritual needs assessed. Perhaps the conclusion would not have been unanimous if some patients did not consider themselves as spiritual. It would have been interesting to have a more balanced sample in regard to the views on spirituality and religion.

    This study is useful to raise awareness about the importance of addressing spirituality. More research is needed in order to develop training programs and screening tools that nurses can use with their patients to facilitate their assessment.

    Reference: Puchalski, C. (2006) Spiritual assessment in clinical practice. Psychiatric annals. 36(3) 150-155

    Conflict of Interest:

    None declared

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  4. Amazing low use of P2 Y12 inhibitors following ACS

    Following ACS (with or without PCI) the use of P2Y12 receptors receptors inhibitors are almost invariable, unless contraindicated absolutely. Use of such drugs only in 49% is exceptionally low, particularly in a regulated health system like that of Finland. There is need to understand why it is so low? Were patients with non- life threatening conditions not put on P2Y12 inhibitors? The study casts more doubts than it solves it.

    Conflict of Interest:

    None declared

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  5. NICE guidelines fail to provide evidence on first line fertility treatment

    We note the recommendation that NICE together with HFEA should provide fertility guidance on what is offered (1). Although HFEA have no legal jurisdiction in providing guidance, NICE have failed to address several important points in the evidence review for first line treatment options (2). The original NICE document proposing that IVF should be offered over intrauterine insemination (IUI) was controversial to such an extent that an update review was initiated to take into consideration a more recent RCT with an emphasis on a specific question: 'What is the effectiveness of IUI in people with unexplained infertility, mild endometriosis or 'mild' male factor infertility?' (2). However, despite the recent evidence review which interestingly has also reworded the original question to 'What is the evidence for IUI, with or without ovarian stimulation, compared with expectant management for people with unexplained infertility, mild endometriosis and mild male-factor infertility, and whether the 2013 recommendations should be updated?', NICE continues to state that 'The lack of high quality evidence available and included in this evidence review was noted'. This recommendation was based on low dose clomid/ IUI yielding poor outcomes which NICE fail to qualify, while omitting gonadotropin stimulated cycles. NICE fail to disclose the limitation of their recommendations (2).Significantly, NICE has only earmarked the comparison of IUI with IVF for 2017, thereby providing definitive guidance before having considered the evidence.

    This premature non-evidence based NICE guidance for first line fertility treatment options favouring expensive IVF procedures is contentious, and in the absence of a valid RCT comparing IUI with IVF is widely rejected (3). The 13 fold increased use of IVF procedures could not have been founded on evidenced based medicine (4), as would the unusually increased 2.9 fold classification of male factor infertility which would justify ICSI procedures.

    Fund holders have to pay a high price for unjustified IVF procedures and financial analysis has shown that IUI is still a cost effective treatment option. In one analysis, IVF was 43,375 Euro more expensive than IUI (5), with a possible annual cost saving of at least 20 million Euro in Europe is possible (6). Globally 74 million subfertile couples cannot access IVF procedures and IUI is their main option (4). For all these reasons clinicians and funding agencies should remain cautious of NICE fertility recommendation (2).

    References:

    1. Spencer E, Mahtani K, Goldacre B, et al. Claims for fertility interventions: a systematic assessment of statements on UK fertility centre websites. BMJ Open, 2016;6:e013940

    2. Fertility problems: assessment and treatment, NICE guidelines [CG156] Published date: February 2013 Last updated: August2016 https://www.nice.org.uk/guidance/cg156

    3. Kim D, Child T, Farquhar Intrauterine insemination: a UK survey on the adherence to NICE clinical guidelines by fertility clinics. BMJ Open, 2015

    May 15;5(5):e007588. doi: 10.1136/bmjopen-2015-007588. 4. Bahadur G, Homburg R, Muneer A, Racich P, Alangaden T, Al-Habib A, Okolo S. First line fertility treatment strategies regarding IUI and IVF require clinical evidence. Hum Reprod, 2016 Jun;31(6):1141-6.

    5. Tjon-Kon-Fat RI, Bensdorp AJ, Bossuyt PM, Koks C, Oosterhuis GJ, Hoek A, Hompes P, Broekmans FJ, Verhoeve HR, de Bruin JP et al. Is IVF-served two different ways-more cost-effective than IUI with controlled ovarian hyperstimulation? Hum Reprod, 2015; 30:2331-2339.

    6. Haagen EC, Nelen WL, Adang EM, Grol RP, Hermens RP, Kremer JA. Guideline adherence is worth the effort: a cost-effectiveness analysis in intrauterine insemination care. Hum Reprod, 2013 Feb;28(2):357-66.

    Conflict of Interest:

    None declared

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  6. Re:reference neglected

    Dear Babak Khoshnood,

    Thank you for taking the time to read our article and respond to it. We did identify your paper in our literature search but it did not meet the inclusion criteria for our systematic review. This was because although the paper was published in 1996 the data contained in it was from 1990. We only included papers reporting data for births from 1994 onwards. If papers contained data from both before and after 1994 (e.g. data from 1992 to 1996) we did include them in our review, but papers with data from entirely before 1994, such as yours, were not included. This was because the routine introduction of surfactant in the mid-1990s impacted on survival and subsequently length of stay.

    Kind regards,

    Sarah Seaton, on behalf of all authors.

    Conflict of Interest:

    None declared

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  7. Commentary: Symptoms in patients with takotsubo syndrome: a qualitative interview study

    Wallstrom, S., Ulin, K., Omerovic, E., & Ekman, I. (2016). Symptoms in patients with takotsubo syndrome: a qualitative interview study. BMJ open, 6(10), e011820.

    The study "Symptoms in patients with takotsubo syndrome: a qualitative interview study" was a very interesting read. As a critical care cardiology nurse in Canada I found the results very informative for practice. I really appreciated that this phenomenon was explored by two registered nurse interviewers.

    One section that was well done that is often not included in qualitative studies was the Methodological considerations section. Each aspect of trustworthiness was broken down and justified in terms of this study. However, no justification for the sample size of n=25 was mentioned, nor was the idea of data saturation. In the strengths and limitations information box, small sample size was listed as a limitation; yet in the methodological consideration section the sample size was discussed as being large for a phenomenological study. For qualitative research the value is placed on richness of data rather than number of participants. I wonder if saturation had been the goal, would there have needed to be so many participants. The use of quotations helped to illustrate the themes, but I would have liked to see some longer quotations in the original context to deepen the richness of the study.

    Overall I really enjoyed this study, and I believe it is very relevant to practice. As a practicing cardiology nurse who sees 5-10 takotsubo patients per year, I will be adapting my practice to include more discussion of illness narratives. I will also be including more focused discharge educating for my clients on expectations regarding residual symptoms, as it seems this was a key concern of many of the patients interviewed. I think this study has very important and relevant findings for cardiology nurses who treat takotsubo patients.

    These findings could be particularly useful when placed in the context of Leventhal's Self-Regulatory Model (Leventhal & Cameron, 1987) to answer the need for further research on integrating illness experience and symptoms into patient-centered care. This model explains how people build perceptions of their illness based on what makes sense to them, how these perceptions then influence their coping behaviors, and how they evaluate their coping responses. I think integrating the finding of this study with this model could help to prevent initial maladaptive coping that was found in the Fear of permanent illness section. I think this could be an interesting area of future study for intervention with takotsubo patients considering the significant amount of worry expressed by participants surrounding residual symptoms. Further research is undeniably needed on this important topic of symptom and illness experience.

    Laura Craigie R.N., BN(I)., CCN(C). Student of Master of Science Applied in Nursing Education Ingram School Of Nursing McGill University Montreal, Quebec Canada

    Conflict of Interest:

    None declared

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  8. Re:Commentary on Female genital cosmetic surgery: a cross-sectional survey exploring knowledge, attitude and practice of general practitioners

    Dear Ms Hasson,

    Thank you for your comments. Most of the points you have raised have already been discussed in the body of the paper and in the interests of maintaining the focus on the significance of the key findings which were: the high rate of genital anxiety, mental health concerns afflicting the women and girls seen by these GPs, sociocultural influences that are modifiable, the lack of GP knowledge around FGCS and the frequency of teen requests, references supporting the statements made were attached for the reader to explore further. Incorporating these detailed explanations within the body of the paper would have rendered the article verbose.

    References 25 and 33 explain how GPs see a complex range of issues per consultation, with many of them involving a mental health component. Reference 25 is a seminal work and analyses general practice consultations over 10 years. This paper outlines how the 'average' GP consultation, is more complex than it appears at first. Harris et al (ref. 33) go on to point out thoughtfully that general practitioners who practise in particular areas of interest, be this 'women's health', 'palliative care', 'sports medicine', eventually select out their patient base over time and will therefore see more of the same and therefore become 'specialists' in certain fields of practice. Harris et al then extrapolate that although this is of benefit to patients who seek the opinion and care of a highly specialised GP whose judgement patients can trust, this also raises issues for the 'generalist' nature of general practice over time. It is a reality, that female patients will prefer to see the female GP within a practice for their gynaecological concerns, as stated by the male GP who was quoted, that in his 30 years of women's health, he had not been asked about FGCS once but knew that his female colleagues had been. Of the 11,000 GPs who received the survey, there were 443 full survey responses, most of these were female GPs (74%), with women's health (77%) interests. Notably, very few GPs who responded to the questionnaire, did not practise in areas of women's health, sexual health, mental health or obstetrics. This very small group overall responded that they had not been asked about genital anatomy, nor had they been asked about FGCS and did not rate their knowledge of FGCS as they had never experienced such requests. The results speak loudly and it does appear that self-selection has occurred. This constitutes the strength of the research findings but also limits our ability to extrapolate to the rest of the GP population.

    Examination of the patient is the standard recommendation of RCOG, BritsPAG, SOGC and the RACGP. The RACGP guide is to date the only freely accessible comprehensive guide for health practitioners available and has drawn from these and other international peak bodies who have developed position statements regarding FGCS. The RACGP guide outlines that the first role of the GP or health practitioner is to 'listen to the patient', then to take a 'psychosexual history' as a baseline and then to perform an examination of the patient. If mental health issues, abuse issues, relationship issues are disclosed, launching into a physical examination of the genital region might not be the most appropriate next step. This can take place at a subsequent visit and often these consultations become a 2 part visit. This brings us back to references 25 and 33.

    GPs in this study noted that their own view of 'normal' genital anatomy was based on experience and often commented that they felt that the term 'normal' was inappropriate as the range of diversity which they have seen is broad, and it is this that constitutes their version of 'normal'. Another note which is referenced in the paper (ref 24), points out that there is a paucity of education around genital anatomy in the medical curriculum and in the absence of educational material, GPs with a limited female patient base might lack confidence reassuring women of normality.

    Indeed, it would be of interest to follow up the survey respondents following the launch of the RACGP guide to see how this has impacted their practice, although to date the feedback RACGP has received is that it is a very useful resource, which has filled a much needed gap. Analysis of the RACGP guide downloads reveals it has been frequently accessed by health professionals around the globe.

    One again, thank you for your questions and interest in this research.

    Sincerely,

    Magdalena Simonis

    Conflict of Interest:

    Author of RACGP guide; RACGP Expert Committee Quality Care

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  9. Commentary Response

    This commentary is in response to: Guedes, D. T., Vafaei, A., Alvarado, B. E., Curcio, C. L., Guralnik, J. M., Zunzunegui, M. V., & Guerra, R. O. (2016). Experiences of violence across life course and its effects on mobility among participants in the International Mobility in Aging Study. BMJ open, 6(10), e012339.

    Firstly, the article was very interesting and was easy to read when going through each section. For the introduction, the article provided information on the data gaps present in the current literature that analyzes life course exposure to violence and the functional health of older adults. These data gaps are: 1) a lack of studies looking at the long-term effects of violence exposure throughout life on the functional health of older adults and 2) whether the possible pathways of this relationship may have a different effect when comparing between men and women. The article separately provides the prevalence rates of mobility disability in older adults as well as findings that show how domestic violence has an impact on outcomes such as: obesity, chronic conditions, pain etc. However, there is a lack of information of these two factors combined together in order to see what is the prevalence and incidence of individuals with lifetime exposure to violence who have disabilities with their mobility later on as older adults. Is the incidence of this population increasing? Does it pose problems for the healthcare system in terms of finance, resources etc.? Is it relevant to conduct research on this population? The article could have provided statistics on either prevalence or incidence of these individuals and could have also incorporated the geographical occurrence (since the study was conducted in five different locations) so that it may provide the reader an understanding of why research is needed for this population. Therefore, an inclusion--in the introduction section--of a paragraph on the population of individuals who have had lifetime exposure to violence and mobility disability later on in life could have helped strengthen the findings of this study in terms of their relevance towards a need to understand these individuals.

    Also, to add a smaller comment concerning the inclusion and exclusion criteria of the study, these were very well laid out. The study mentioned the participants that were excluded as well as the composition of the study population. However, a description of the study's required level of cognitive impairment (such as: memory, mood, functional status) when recruiting participants could have been mentioned in the inclusion criteria. This is because the Leganes Cognitive Test (LCT) was used to screen individuals with severe cognitive impairment and so, a brief mention of the cognitive requirements of the participants could have been provided in the inclusion criteria for participants.

    Conflict of Interest:

    None declared

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  10. Stress fractures and premenstrual syndrome's commentary

    The study "Stress fractures and premenstrual syndrome" conducted by Takeda and al highlights the relationship between the occurrence of stress fractures and premenstrual syndrome. What I found very interesting about this research is in regards to the findings, which defines a population more at risk in some specifics sports. Furthermore, a noticeable strength of the study is the use of the Premenstrual Symptom Questionnaire based on the DSM-4 criteria. This allows for an extensive evaluation of this factor.

    With the use of a retrospective cohort design the author was able to identify risk factors and understand what causes women to be more likely to develop stress fractures. However, a prospective cohort design would have addressed the issue of temporality, whether exposure preceded the fracture. Additionally, the selected sample (women athletes) allowed the findings to be generalized to a larger population and enhanced external validity. However, the selected women had regular menstrual cycles without taking hormonal therapy. This is an exclusion criterion that can negatively affect the generalizability of the findings to other cultures. For example, in Canada, nearly 1/3 of women between the ages of 15-19 take birth control pill (Statistic Canada, 2015). Also, only including women with regular menstrual cycles may be contributing to selection bias, by ensuring the sample obtained is not representative of the population intended to be analyzed.

    One of the weaknesses of this article is the triad. When establishing that female athlete triad is a significant risk factor for stress fractures, it would have been relevant to assess each factor more precisely. First of all, an eating disorder is a diagnosis on its own, using a screening tool that has been shown to correlate with a clinical diagnosis like the SCOFF questionnaire (Morgan and all, 1999) would have been relevant. Since it is a short (only 5 questions) but highly effective tool, it would have been feasible to incorporate this into the study. Eating disorders may have a paramount importance and even be a confounding factor in the development of stress fractures as they are associated with an increased risk of osteoporosis. Moreover, it would have been relevant to at least report any osteoporosis/osteopenia that would have been diagnosed during the care associated with the stress fracture.

    In the multivariate analysis, the BMI is used as a dichotomous variable to assess the probability of developing a stress fracture when the athlete is underweight. The results show that a women athlete <18.5 kg/m2 is twice as more likely to have one, however, this was not statistically significant (P value = 0.108). The sample may possibly be too small, reducing the statistical power of the study and resulting in the analyses failing to show that being underweight and stress fractures are significantly related. Moreover, it would have been relevant to assess the BMI of people with a fracture.

    References

    Solmi, M., Veronese, N., Correll, C. U., Favaro, A., Santonastaso, P., Caregaro, L., . . . Stubbs,

    B. (2016). Bone mineral density, osteoporosis, and fractures among people with eating

    disorders: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 133(5),

    341-351. doi:10.1111/acps.12556

    Morgan, J-F., Reid, F., Lacey J H. (1999). The SCOFF questionnaire?: assessment of a new

    screening tool for eating disorders. BMJ, 310, p.1467-1468

    Statistic Canada.(2015). Pr?valence de l'utilisation des contraceptifs oraux, selon certaines caract?ristiques, femmes de 15 ? 49 ans, population ? domicile, Canada, 2007 ? 2011

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