1208 e-Letters

  • PAGE: Paediatric Admission Guidance in the Emergency Department

    We read with interest the assessment tool given the acronym PAGE: Paediatric Admission Guidance in the Emergency Department.

    This PAGE study is of particular importance in emergency departments
    in a hospital ( for instance in Oman ) where pediatrics is not amongst a hospital specialities.

    Further development of PAGE may answer a recent call to improve the Emergency Department (ED) response to children injuries in Oman.

    doi: 10.1136/bmjpo-2018-000310

    A recent retrospective review of ED trauma registers in Oman also found, first, high children injuries incidence of falls, home injuries and burns.
    Second, suggests future work for age-targeted interventions to better respond to children injury events .

  • Protocol extension

    Dear Editors,
    We would like to inform you and the readers of BMJ open that we plan to slightly enlarge the enrollment of our trial "Randomised, non-inferiority, controlled procedural outcomes TrIal comParing reverse T And Protrusion versus double-kissing and crush stenting: protocol of the TIP TAP I randomised trial", which was published in BMJ Open. 2020; 10(6): e034264. Our original intention was to recruit 50 patients. Unfortunately, the OCT data pertaining the primary endpoint of the study could not be assessed in two of the patients. We therefore plan to recruit 2 additional patients following the same procedures. The analysis population of the study will therefore maintain its previously planned size of 50, the safety and IIT populations will however include all 52 patients.

    Safety outcomes have been and will be regularly reviewed by three cardiologists who are not involved in any procedure of the study.

    Tommaso Gori

  • International Passenger Capacity

    "We however found that the main determinant was the total number of international arrivals in the country (2018 figures), signifying transmission of the infection through travel. Although the data were from 2018, there is no reason to believe that international travel figures between countries would be different in early 2020."

    The study period from December 2019 to June 2020 covered a period in which international passenger capacity reduced by 8% in February 2020, by 46% in March 2020 and by 90% in April 2020 year-on-year compared to 2019 (ICAO data). It is therefore demonstrably incorrect to assert that there is no reason to believe travel figures would be different.

  • The limitations of body mass index - response

    Dear Dr Bhakta and Dr O'Brien,
    We are grateful for the very valid insights. Our intention was not to explore BMI as a COVID risk factor due to reasons such as incomplete data and measurement accuracy, but to account for it as a potentially confounding variable in the relationship between ethnicity and outcome. Evidence regarding ethnic differences in BMI remains sparse and historic reports may not accurately reflect cohorts represented in contemporary publications. This is nevertheless an important subject to address for future research.
    Yize I Wan,
    John R Prowle

  • Methotrexate in erythema nodosum leprosum (MaPs in ENL)

    We read with interest the MaPs in ENL study protocol (de Barros et al, BMJ open 2020).[1] The availability of an alternative drug for cases of chronic or recurrent type 2 lepra reaction with steroid toxicity or unresponsiveness is the need of the hour and although drugs like thalidomide, cyclosporine etc. are prescribed in such patients but cost, adverse effect or non-availability are the major deterrents in their use. The researchers must be complimented for their bold decision to choose methotrexate based only on case reports or a short series of patients (15 patients in total were given methotrexate for type 2 reactions).[2] This is a well-designed protocol aimed at possibly adding another drug to our therapeutic armamentarium for the crippling erythema nodosum leprosum (ENL) reactions. If found useful, methotrexate has the advantage of being a cheap, easy to administer and readily available drug.

    The study proposes to randomize patients with acute, chronic or recurrent ENL into two groups, receiving 20 weeks of prednisolone with either 48 weeks of methotrexate or placebo. While use of methotrexate is justified in patients with chronic and recurrent ENL, , same might not be applicable to cases of acute ENL. Acute ENL, by definition, is an episode that lasts lesser than 24 weeks,[3] as has been defined in the study protocol as well. Most of these cases with acute episode respond well to corticosteroids, clinical response has been observed as early as in 2 week...

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  • Comparing outcomes between ethnic groups - the limitations of body mass index.

    Dear Editor,
    Apea VJ et al. should be congratulated on elucidating the interplay between overlapping factors that influence patient outcomes from COVID-19. From the first reports about this disease, observers have noted that adipose tissue, perhaps through its association with diabetes and heart disease, has been linked to the severity of presentation and to subsequent clinical course. In studying a cosmopolitan patient population in a single large centre, the authors have cleverly eliminated many confounding factors and allowed the influence of ethnicity, per se, to be assessed.
    In this context though, the use of body mass index as a measure of obesity may be too blunt a discriminator. While a BMI of 30 kg/m2 is conventionally taken to define obesity, this measure has significant limitations.2,3 The most obvious is that it does not actually measure lean versus fatty tissue.3 More particularly, the BMI or Quetelet index threshold of 30 kg/m2 may be insensitive to the presence of obesity in those of Asian origin.4 Other authors have shown that the cut off in Asians may be optimally set at a lower level (e.g. 27 kg/m2 for men, and as low as 25 kg/m2 for women).5 We wonder, were Apea VJ et al.’s observations re-examined using such thresholds, if the poor outcomes seem in Asian patients would be more fully accounted for?
    We would welcome their views on this question. As the world’s most populous countries are in Asia, and the...

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  • Antibiotics save admissions and lives.

    Goodness who would have thought it, antibiotics can save admissions and probably lives. After years of vilifying GP's for high antibiotic prescribing we now know the truth. Appropriate prescribers are probably those more accessible with higher consultation rates and higher prescribing rates. Some times the better GP's aren't always those that do as they are told.

  • Response to comment of Aleksandar Ćirković and rebuttal of the suggestion of additional limitations

    This is a response to a comment on the paper dated 20 January 2021.

    Dear Dr. Ćirković,

    We thank Ćirković for welcoming our study. Before answering the points raised by Ćirković I first mention a currently-under-peer-review scientific communication between myself and the editor of the journal which published the article authored by Ćirković, that he cites in his comment [1]. The full text of this Letter to the Editor has been available as a preprint in the public domain since 18 Dec 2021 [2].

    - I address below the points raised by Ćirković on his comment on our BMJ Open paper in turn:

    1. TRIPOD and PROBAST checklists - searching the clinical literature using PubMed and Google Scholar identifies no studies that have used these checklists in the evaluation of vignettes studies or studies of symptom assessment applications. We reviewed the literature on symptom assessment app in our paper, and I have looked again at each of these papers, and none of them used the TRIPOD or the PROBAST checklist, nor did a recent paper in this domain from an independent academic group [3], nor did Ćirković himself in [1]. The TRIPOD checklist (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) is designed for studies into diagnostic and prognostic models for clinicians, and although an interesting suggestion, the use of such a checklist is not compulsory and not having adopted it is not a study limitation in itself. The P...

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  • Five missing limitations to this evaulation

    The study is a welcome addition to the yet sparse database of evaluations of self-diagnosis tools that, unlike expert systems, are to be put into patients’ hands directly. However, there are some limitations missing in the Discussions section that I’d like to add. Firstly, as these self-diagnosis tools can have a significant impact on public health [1], it will be crucial for regulating authorities and lawmakers to create a framework that correctly distributes the liabilities on the participants in the system and ensures a positive ratio of benefit vs risk; this will only be possible if there is enough robust information available on the respective systems/programs/apps to thoroughly assess them. As this novel field is just unfolding, there are plenty of obstacles on the way to a truly objective assessment of AI-driven software, as Nagendran et al recently demonstrated here in the BMJ. [2] They used, among others, the TRIPOD and PROBAST checklists for evaluating the validities of respective studies. A quick check on this study with both would give a result of a TRIPOD adherence of 18 of 24 relevant checklist items and a high risk of bias when using the PROBAST checklist. The release of an updated TRIPOD checklist with a focus on AI-driven software has also been announced and will then be relevant for the evaluation of this study. [3] Thus, incomplete adherence to the present and unknown adherence to the presumably relevant future TRIPOD statements and a high risk of bias a...

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  • Response to comment of Oscar Garcia-Esquirol and rebuttal of the suggestion of study bias.

    This is a response to a comment on the paper dated 7 January 2021.

    Dear Oscar Garcia-Esquirol, Cofounder and Chief Medical Director at Mediktor, one of the symptom checkers evaluated in the study,

    Thank you for your comment on this paper.

    Your letter addressed strong criticism at the paper [1] with respect to bias. I will answer these points in turn below. Our study included a rigorous design process conducted by experienced clinical researchers, data scientists and health policy experts, with the methodology and analysis peer-reviewed by independent and experienced primary care physicians and medical informatics experts at universities in the UK, and in Brown University in the US. To ensure a fair comparison, our team used a large number of clinical vignettes, which were generated from a mix of real patient experiences gleaned from the UK’s NHS 111 telephone triage service and from those generated from the many years’ combined experience of the research team. The gold-standard triage level used in the study was set independently of vignette creation, vignette review and vignette diagnosis gold-standard setting - this was done by a separate panel of three experienced primary care practitioners using a tie-breaker panel method based on the matching process set out by [2].

    A strength of this paper is that it not only compares a range of symptom assessment apps to each other, but also compares their performances to that of practicing GPs. While the...

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