To the Editor
We had previously published an article in this journal on effect of damage
to descending motor corticofugal fibers on motor deficit and disability
post stroke1. These corticofugal fibers (primary motor cortex (CSTM1),
premotor area (CSTPMd) and supplementary motor area (CSTSMA)) are close to
each in the corona radiata, posterior limb of the internal capsule and
lateral brainstem. Due to the close spatial rela...
To the Editor
We had previously published an article in this journal on effect of damage
to descending motor corticofugal fibers on motor deficit and disability
post stroke1. These corticofugal fibers (primary motor cortex (CSTM1),
premotor area (CSTPMd) and supplementary motor area (CSTSMA)) are close to
each in the corona radiata, posterior limb of the internal capsule and
lateral brainstem. Due to the close spatial relationship among these
fibers, statistical analysis to determine the independent effect of these
fibers was not performed in our earlier publication. Recently, we have
come across the method of hierarchical partition which can be helpful in
finding important predictors2 . We report here a re-analysis of previously
published work by this group1.
The hierarchical partition method attempts to partition the goodness
of fit of the models (hierpart package, R Statistical Foundation). The
generalised R2 for motor arm and leg deficit was 0.33. The analysis showed
that M1 tract had greater (42% of the variance) independent effect on
motor arm deficit than other corticofugal fibers (see Figure 1). Age had
the lowest contribution in this model. The analysis showed that age (40%
of variance) had greater independent effect on motor leg deficit than
corticofugal fibers . The generalised R2 for the disability model was
0.52. The analysis showed that M1 tract (34% of variance) had greater
independent effect on disability than other corticofugal fibers. Age had
higher contribution in this model for disability and leg motor deficit.
Figure 1-corticofugal fiber involvement and Rankin disability score
These corticofugal fibers (primary motor cortex (CSTM1), premotor
area (CSTPMd) and supplementary motor area (CSTSMA))
Figure 1b-corticofugal fibr involvement and NIHSS arm item
Figure 1c- corticofugal involvement and NIHSS -leg item
Disclosure:
None
Sources of Funding
Dr Srikanth reported receiving a NHMRC/Heart Foundation Career Development
Fellowship (ID:606544). These funding sources had no role in study design,
data collection, data analysis, data interpretation, or writing of the
report.
References
1. Phan TG, van der Voort S, Chen J, Beare R, Ma H, Clissold B, et al.
Impact of corticofugal fibre involvement in subcortical stroke. BMJ Open.
2013;3:e003318
2. Mac Nally R. Multiple regression and inference in conservation biology
and ecology: Further comments on identifying important predictor
variables. Biodiversity and Conservation. 2002;11:1397- 1401
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...
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/
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 b...
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.
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
aspe...
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
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 solv...
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.
I read with interest your systematic review of the predictor factors
for length of stay in a neonatal unit. I was surprised however that the
article did not cite a paper we did a long time ago (1996), which was
nevertheless within the time range of the search strategy for identifying
relevant papers. The title of our article was "Models for determining cost
of care and length of stay in...
I read with interest your systematic review of the predictor factors
for length of stay in a neonatal unit. I was surprised however that the
article did not cite a paper we did a long time ago (1996), which was
nevertheless within the time range of the search strategy for identifying
relevant papers. The title of our article was "Models for determining cost
of care and length of stay in neonatal intensive care units." and the
paper was published in Int J Tech Assessment in Health Care 1996
Winter;12(1):62-71.
Given the title of our paper and its scope, I am not sure why this
paper could not be identified / cited for a systematic review on the
subject. I am not sure there is anyway to rectify this but I thought it
would be justified to at least mention the problem.
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 arou...
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
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 phe...
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
Please note that the following information was correctly reported in
the tables but incorrectly cited in the text. These corrections do not
affect the analyses or conclusion of the article as the interpretation
remains correct.
1. Among the oral anticoagulant experienced group of patients, the
amount of time since atrial fibrillation diagnosis was reported in years
instead of months. Page 6 should read as follo...
Please note that the following information was correctly reported in
the tables but incorrectly cited in the text. These corrections do not
affect the analyses or conclusion of the article as the interpretation
remains correct.
1. Among the oral anticoagulant experienced group of patients, the
amount of time since atrial fibrillation diagnosis was reported in years
instead of months. Page 6 should read as follows:
"However, the median time since AF diagnosis was more varied between the
OAC cohorts than in the OAC naive group: VKA 5.4 months (IQR 1.7 to 19.1),
dabigatran 40.7 months (IQR 11.5 to 89.4), rivaroxaban 54.2 months (IQR
18.2 to 109.0) and apixaban 44.2 months (IQR 13.8 to 91.9; table 2)"
2. The total number of patients for whom oral anticoagulant
persistence was assessed was reported as 11,657 (89.1%) instead of 11,647
(89.0%). Page 6 should read as follows:
"Of the 13 089 OAC naive patients, persistence was assessed for 11 647
patients (89.0%) (9303 VKA, 1275 rivaroxaban, 656 dabigatran and 413
apixaban) who had a sufficient amount of follow-up"
3. The persistence rate of vitamin K antagonists at 3 months of
follow-up was reported as 93.4% instead of 93.9%. Page 7 should read as
follows:
"At 3 months' follow-up, persistence was high across all OAC cohorts
ranging from 84.1% (95% CI 81.2% to 86.8%) in dabigatran users to 93.9%
(95% CI 93.4% to 94.4%) in VKA users"
4. The numbers of patients for whom persistence could be assessed at
12 months of follow-up were incorrectly cited in the text as "... in the
apixaban cohort (n=70) compared to the other OACs (rivaroxaban n=493,
dabigatran n=377, VKA n=4979)." Page 7 should read as follows:
"However, it should be noted that the number of patients assessed at 12
months was particularly low in the apixaban cohort (n=21) compared to the
other OACs (rivaroxaban n=227, dabigatran n=189, VKA n=3321)"
5. In the sensitivity analysis where international normalised ratio
records were removed from the definition of vitamin K antagonist
persistence, the rate at 12 months of follow-up was reported as 61.2%
instead of 61.7%. Page 10 should read as follows:
"The removal of INR records from VKA persistence also lowered VKA
persistence: the 12-month VKA persistence changed from 77.8% (95% CI 76.8%
to 78.7%) to 61.7% (95% CI 60.0% to 63.4%)"
Conflict of Interest:
Author of the published article and employed by OXON
Epidemiology, which received funding from Bristol-Myers Squibb to
conduct the published analysis.
To the Editor We had previously published an article in this journal on effect of damage to descending motor corticofugal fibers on motor deficit and disability post stroke1. These corticofugal fibers (primary motor cortex (CSTM1), premotor area (CSTPMd) and supplementary motor area (CSTSMA)) are close to each in the corona radiata, posterior limb of the internal capsule and lateral brainstem. Due to the close spatial rela...
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
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...
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 b...
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 aspe...
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 solv...
Dear Sarah Seaton et al,
I read with interest your systematic review of the predictor factors for length of stay in a neonatal unit. I was surprised however that the article did not cite a paper we did a long time ago (1996), which was nevertheless within the time range of the search strategy for identifying relevant papers. The title of our article was "Models for determining cost of care and length of stay in...
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 arou...
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 phe...
Please note that the following information was correctly reported in the tables but incorrectly cited in the text. These corrections do not affect the analyses or conclusion of the article as the interpretation remains correct.
1. Among the oral anticoagulant experienced group of patients, the amount of time since atrial fibrillation diagnosis was reported in years instead of months. Page 6 should read as follo...
Pages