582 e-Letters

published between 2016 and 2019

  • The Summary Care Record: A Forgotten, Underutilized, But Indispensable Tool in the Era of Electronic Records

    Dear Editor,
    We read the excellent article by Warren and colleagues [1] with interest and agree wholeheartedly with the need for consolidated access to health records for clinicians across the healthcare ecosystem in the UK.
    As junior doctors, we are often left with the laborious task of sourcing and amalgamating these disparate records for individual patients, with patients often surprised that we do not have access to all their information.
    We note the authors recommend the common adoption of the same EHR software for trusts in the same region and the transfer of records between systems by open APIs. These aims are laudable, however, remain problematic:
    1) Utilising the same EHR between NHS trusts does not necessarily guarantee any further ease of transfer than alternate EHRs; many trusts customise their EHR to their local preferences and hence implementations and data structures may vary significantly between trusts despite adopting the same EHR [2]. Further, even with the same systems, each trust will likely operate on differing domains, often requiring lengthy governance processes to facilitate transfer of records.
    2) Open APIs such as Fast Healthcare Interoperability Resources (FHIR) [3] are available and implemented by the 3 major EHR vendors in the UK [4–6]. Despite this, exchange of records between different NHS trust systems remains limited.
    The Summary Care Record (SCR) was initially intended as a repository of essential medic...

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  • Response to comment regarding “Early childhood vaccination and subsequent mortality or morbidity: are observational studies hampered by residual confounding? A Danish register-based cohort study”

    In our previous response we listed a number of differences between the study by Jensen et al.[1] and the studies by Sørup et al.[2, 3]. We thank Jensen et al. for providing the estimates for a restricted cohort of children who received 2 doses of DTP before 11 months of age (Table 1: https://bmjopen.bmj.com/pages/wp-content/uploads/sites/7/2019/11/table-1...). However,
    restriction of the cohort to children with 2 DTP vaccines before 11 months of age only removes a limited part of the differences we mentioned; hence, the results in Table 1 are still incomparable to the previous studies by Sørup et al.
    Jensen et al. included the 2DTP+MMR group in the modelling of effects (which Sørup et al. did not), and they did not analyse the data by type of infection, by sequence of vaccinations, and by the many confounders we had used. Since we specifically limited our studies to the period before PCV was part of the routine immunization programme, it should be noted that Jensen et al include many years where PCV was used (2007-2016). The introduction of PCV, a vaccine against respiratory infections, may have eliminated the need for some of the beneficial non-specific effects of MMR.
    Rather than testing something else, finding something else, and concluding that previous studies testing and finding different things were flawed, the fruitful way forward would be to investigate the...

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  • Points to be considered when using cardio ankle vascular index (CAVI) as a marker of arterial stiffness

    Letter to editor:
    We read with interest the article by Zhang et al. [1], in which they concluded that total hip bone mineral density was correlated with cardio ankle vascular index (CAVI). However, some common mistakes can happen in the studies using CAVI as a marker of arterial stiffness. First, Pearson’s correlation between this marker and other continuous variables should be considered after testing both variables for normality. Normality of the variables had been proposed as an assumption for the Pearson’s correlation analysis [2], if this assumption is not met, Spearman’s correlation should be performed after categorization of the continuous variables.
    Second point that is essential in evaluation of CAVI is the effects of age on CAVI. Age has been proved to be largely correlated to CAVI and many studies tried to make reference values for CAVI in different age groups. Namekata et al. [3] provided reference values which can be used to categorize CAVI in the study individuals. Although Zhang et al. [1] controlled for age in the multiple linear regression, using reference values of CAVI in every individual could completely change the results and conclusions of their study. Although in the study of Zhange et al. [1] we can see the biggest correlation (r=0.631, P<0.001) between age and CAVI, correlation of age with other variables cannot be seen and there is a possibility that age and bone mineral density is also high. So, conclusions about the independent as...

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  • In reply to the authors' response to "Concerns regarding the inference that EDS is not rare"

    We thank Demmler and colleagues for their reply to our concerns (dated 29th November 2019). In particular we appreciate the analysis required to demonstrate that the Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos syndromes (EDS) cohorts in their study shared similar characteristics across the 35 Read chapter categories. This is a valuable observation of itself.

    Demmler and colleagues say in their reply that we ‘asserted that diagnosed JHS is known to be common’. We assume they have misconstrued our opening comments about combining common with rare conditions. We used the words ‘common’ and ‘diagnosed JHS’ to describe their findings, and based on the prevalence of ‘diagnosed JHS’ in the population they studied. We recognise that this study is the first to directly report a healthcare record-based population prevalence for JHS and a healthcare record-based population prevalence for EDS.

    We read that the authors agree with our comments that it is not possible to know what proportion of people who met the Brighton criteria for JHS also meet the 2017 hEDS criteria, and, that the authors agree that further studies are required to determine how common hypermobility spectrum disorder (HSD), hypermobile EDS (hEDS), and other forms of EDS are.

    We appreciate that the authors did not “seek to remove the protected ‘rare’ status from all subtypes of EDS”, and that they “regret if their work has been misquoted on social media”. Demmler et al. also reply that...

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  • Changes to Statistical Plan

    We hereby write to inform the readers of changes to the statistical plan for our clinical trial MAGiCAL-CKD, which we have previously published in BMJ Open. At the time of writing, the trial is still on-going and the data set has not been unblinded. Thus, any changes to the statistical plan at this time will not compromise the integrity of the trial design.
    The purpose of the MAGiCAL-CKD trial is to examine the effect of magnesium (Mg) supplementation on coronary artery calcification (CAC) score in patients with chronic kidney disease. The original statistical plan was to analyse the change in CAC score from week 0 to week 52 (delta CAC score) and compare the delta CAC score between the two treatment groups. The choice of delta CAC as the primary endpoint (and not the between-group difference in CAC score at week 52) was made due to the potential for an imbalance in CAC score between the two treatment groups at week 0. The delta CAC was thought to better account for any baseline imbalance. However, since the publication of the trial protocol we have become aware that this methodology is flawed and that the correct analysis is to perform an analysis of covariance (ANCOVA) of CAC score between the two treatment groups at week 52 adjusted for CAC score, age and prevalent diabetes mellitus (yes/no) at week 0. Therefore, the ANCOVA test will be applied to analyse the primary endpoint. Essentially, we are examining the same scientific question, but using better methodology...

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  • Medication use in population with intellectual disabilities is complex: Pharmacists can help

    The healthcare environment in which people with intellectual disabilities (PWID) receive care and are prescribed medication is increasingly complex. PWID and their carers know the complexity of their needs, and they alone know the real gaps in healthcare that can occur in services provided to them. It is important that PWID are included in decisions about their own healthcare of which medication use is a major component. Exercising autonomy in the medication use process can be difficult and may not ensure the highest quality healthcare for PWID who usually are dependent on others for many aspects their care and access to care (1).

    In an Irish qualitative study where 6 people with intellectual disabilities were interviewed about their medicines ,one participant prescribed Stelazine described that when he started taking it his ‘strength went down’ and ‘it was hard to do things’. (Alex). His concerned parent reported being ‘unheard’ during encounters with the prescriber (2).

    Diverse interventions offer promising approaches to improving medication adherence for chronic conditions, particularly for the short term. Evidence on whether these approaches have broad applicability for clinical conditions and populations is limited, as is evidence regarding long-term medication adherence or health outcomes.

    PWID can provide valuable insight into the medication use process.

    Patients who are given and supported to use information to make decisions a...

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  • Reply to “Concerns regarding the inference that EDS is not rare"

    We would like to thank Hakim et al for the opportunity to continue the debate around the prevalence and definitions of conditions associated with joint hypermobility. Coming to anything like a true population prevalence for these conditions is still a long way off due to both the huge under-diagnosis (1) and ongoing evolution of the clinically-based criteria (2-4) and terminology for patients who do not have one of the known genetic mutations for classical, vascular or the other so-called rare subtypes of Ehlers-Danlos Syndrome (EDS).

    Hakim et al assert in their letter that diagnosed Joint Hypermobility Syndrome (JHS) is known to be ‘common’. We have searched the literature for reported whole population prevalence rates for JHS and have been unable to find any. Therefore our paper is the first to report a diagnosed prevalence for this condition, although this figure can also be derived for the population of Sweden, as we pointed out in our work. (5)

    We completely agree with the letter’s authors that at this point in time it is not possible to know what proportion of people who met the Brighton Criteria for JHS also meet the 2017 hEDS criteria. We hope further research may reveal this data in the future. What we can say, however, is that for the decade or so prior to 2017, experts in the field considered JHS and EDS-HT to be clinically indistinguishable (1, 6-10), indeed many clinicians used the term JHS/EDS-HT in correspondence in recognition of this. Indeed,...

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  • Response to Levy et al.

    We are grateful to Levy et al for their comments on our paper.

    Much of the response to the paper has been to the media coverage and potential consequences of this. That MDIs have a large carbon footprint is hardly news within technical and academic literature. (1) It’s fair to say we were taken aback by the media response. Any guilt induced by headlines which focussed on individual change is deeply regrettable. Our paper was focussed on modelling at the NHS level. In-line with other previous reports we included an individual level comparison to provide context to our findings. (1-3) The “180-mile car journey” ascribed to us by Levy et al. originates from a story about NICE asthma inhalers decision aid.(4) Clearly we can’t control the media and have tried to correct errors in media reporting where possible. It is our opinion that it would be unethical and paternalistic to withhold significant information about treatment options from patients. As academic authors we are reflecting on how best to communicate information of the environmental impact of healthcare to the public and media, and considering how we might improve this in the future.

    Levy et al. highlight concerns “that all patients can be summarily switched from pMDIs to DPIs” or that patients are “deprived of access to pMDI therapy”. We do not propose this in the paper. In fact we make suggestions on how to reduce the greenhouse gas emissions from MDIs where their continuing use is necessary by prio...

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  • Key Reference unavailable

    Many thanks for bringing this to our attention. Unfortunately that report has been removed from their website and we are unable to add it now as a supplementary file. Here is an alternative reference published more recently which contains the same information:

    Janson C, Henderson R, Löfdahl M, et al. Carbon footprint impact of the choice of inhalers for asthma and COPD Thorax doi: 10.1136/thoraxjnl-2019-213744

    The findings presented here on the carbon footprint of inhalers are entirely concordant with other previous reports.

  • SAS Doctors

    The paper says "...specialty and associate specialist (SAS) doctors (doctors who have completed specialist training but do not have a staff position)...".

    That's not correct. Firstly while SAS doctors may have completed specialist training, they more often have not. Secondly, a permenent SAS doctor does have a "staff position" in ordinary language. If this is a reference to US-specific terminology then I suspect the problem is that there is no direct equivalent.