959 e-Letters

  • Self-management and self-care, two sides of the same coin

    We read with interest the paper by Van de Velde et al delineating the concept of self-management in chronic conditions.1 We agree that there is a lack of consensus on the meaning of self-management, ambiguity regarding the concept, and an urgent need for uniformity with regard to terminology. One major area of ambiguity is the relationship between self-management and self-care. These terms are often thought of as synonyms, used interchangeably, or considered as integrated concepts (e.g. self-care as an overarching or umbrella term, with self-management as onecomponent of self-care).2 This is why, until 2018, major search engines combined the terms. When one searched for “self-management”, literature on “self-care” was provided as well. Since Van de Velde and co-workers aimed to delineate the concept of self-management and develop a definition for its use in healthcare, we expected a more thorough review of related concepts in their concept analysis. Thus, we were surprised to find that several important publications on self-care were excluded.

    We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managi...

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  • Obstetrics and Gynecology Disclosure of Conflicts of/Competing Interests by Editors

    Thank you for your recent BMJ Open article,1 which has correctly noted that it is critical for journal editors’ potential conflicts of interest to be publicly disclosed. A limitation of the study is that only the digital version of the journals were considered. Obstetrics & Gynecology has included a conflict of interest statement for the Editor-in-Chief and Deputy or Associate Editors on the masthead of the print journal since the July 2008 issue. The article by Dal-Ré has prompted us to review our digital presence, and the website has since been updated to reflect our long-standing presentation of the editors’ potential conflicts of interest. I thank the authors for highlighting the importance of disclosing potential conflicts of interest but express concern that their work is biased toward the digital presence only.

    1. Dal-Ré R, Caplan AL, Marusic A. Editors’ and authors’ individual conflicts of interest disclosure and journal transparency. A cross-sectional study of high-impact medical specialty journals. BMJ Open 2019;9:e029796. doi: 10.1136/bmjopen-2019-029796.

  • Fat Suits no substitute for a Fat Person

    While it is important for medical students, along with those that teach them, to know how to communicate appropriately with their clients of all sizes, a simulation such as a fat suit is NEVER an accurate substitute for speaking with a client that lives every day with a fat body. Unless the person wearing a fat suit has lived with the stigma, discrimination and overt hatred of their body by a medical professional, their is no way the communication/conversation about their bodies will be the same. If you want to learn how to treat a fat client, please read the brochure NAAFA Guidelines for healthcare providers with fat clients available at https://www.naafaonline.com/dev2/about/Brochures/2017_Guidelines_for_Hea....

  • Trends in brain tumour incidence in the 60+ age group in Australia from 1982 to 2013

    We recently reported no increase in any brain tumour histological type or glioma location between 1982 and 2013 in Australia that can be attributed to the use of mobile phones1. Our analysis included brain tumour incidence in adults aged 20–59 years but Phillips2 criticised this age-range mentioning that it was inappropriate not to include the 60+ age group which has the highest incidence of brain tumours. In a response to Phillips3, we reiterated that the age-range in our study was chosen in order to compare our results with the Interphone study4. We further mentioned that including cases older than 60 would be more affected by improvements in diagnosis and their inclusion would reduce the chance of assessing mobile phone related changes to tumour incidence.

    As a follow up to our original analysis, we investigated the incidence trends of brain tumour histological types and anatomical location in Australians aged 60+ diagnosed between 1982 and 2013. The methods of our follow up analysis were the same as our original study1 and the observed incidence trends, given as annual percentage change (APC) and 95% confidence limits, were examined over the time periods 1982–1992, 1993–2002 and 2003–2013 (representing increased CT and MRI use, advances in MRI and substantial and increasing mobile phone use, respectively).

    There was a total of 20300 eligible brain cancer cases aged 60+ that were diagnosed between 1982 and 2013. The observed incidence trends for glioma we...

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  • The demographics and geographic distribution of laboratory-confirmed Lyme disease cases in England and Wales (2013-2016): an ecological study

    This paper is interesting and a welcome addition to the literature. The authors discuss the potential issues related to the use patient post codes. The case of the New Forest, considered a hot spot, is interesting in this regard. The number of residents currently is 38,000 and the annual number of visitors is 13.5 million according to the New Forest District Council.

  • Meeting religious needs as part of spiritual well-being

    In their recent paper, exploring prognostic signs and symptoms in relation to survival of 72 hours, White N, Reid F, Harries P, et al. (BMJ Open 2019), mention that a ‘large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient.’ This comment highlights, in my experience, the absence of documented information about a patient’s psychological and spiritual well-being prior to the final days of life. For some patients, an important aspect of spiritual well-being is religious faith, including the support of a faith community and the opportunity to receive end-of-life religious rites.

    When patients are admitted for end-of-life care, there can be occasions when there is little or no time for an in-patient team to learn about a person’s spiritual or religious needs. This may be due to the fact that a patient is unconscious on admission and there are no accompanying relatives or friends. In such situations, the referral form is crucial. Yet, the pan-London Specialist Palliative Care (SPC) Community and SPC Inpatient Unit Referral Form does not provide a specific ‘religion’ box.

    This form does have a section for ‘any other comments/information (including preferences expressed about care, other psychosocial or spiritual issues or DOLS)’, but almost invariably the referrer fails to mention spiritual or religious needs. Clearly, it is important to know i...

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  • Individual trainee failure rate

    Dear Brandon Togioka,
    Thanks for the interest in the article.
    We actually had similar question ourselves as the numbers were small. The following are the individual trainee failure rates in percentage.

    Trainee number Failure Rate (percentage) Group 1= group S, 2= Group P

    1. 20 1
    2. 10 1
    3. 0 1
    4. 30 1
    5. 10 1
    6. 30 1
    7. 40 1
    8. 30 1
    9. 10 2
    10. 0 2
    11. 0 2...

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  • Response to Clinical specialty training in UK undergraduate medical schools: a retrospective observational study

    Dear Editor,

    In contrast with prior literature - which only focused on a limited number of specialties - HJ Vaidya et al (1) demonstrated that medical students who have a longer placement period in a particular speciality are no more likely to pursue a career in that speciality. The study has important implications, and the authors should be commended, as it suggests that increasing exposure to clinical specialties during medical school will not solve current recruitment pressures.

    Interestingly, the authors chose to incorporate specialties such as clinical radiology and public health within the statistical analysis. However we question the reliability of the subsequent results, given the small number of medical schools that offered placements in those specialities.

    By using the number of weeks allocated to a particular speciality by each medical school, the authors created a useful, objective metric that could be used for statistical analysis. However, upon reading, we noted that it may not wholly reflect a student’s exposure to that speciality during their placement. In our experience as medical students, we feel that due consideration must be given to the quality of a clinical placement as well as it’s duration. The hospital in which a student is based, the medical team that they shadow, and the student’s experience are but some of the factors that may influence the degree of a student’s involvement on a particular firm, thereby influencing their e...

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  • Response to: Methodological bias in comparison of lactate values between Handheld analyser and Blood gas analyser

    Dear Editor,

    Léguillier commented on the methodological biases in our recent study. We thank Léguillier for his interest and here we provide further clarification of the points mentioned in his letter.

    Firstly we would like to clarify that the two handheld analysers used: Nova StatStrip Xpress Lactate Meter (Nova Biomedical, Waltham, USA) and Lactate Scout+ (EKF Diagnostics, Leipzig, Germany), were both calibrated, maintained and tested for quality control by their respective companies. In the absence of prior evidence of the superiority of one make of machine over another, we chose to compare two standard models.

    Regarding the comment on the sample size, the calculated sample size using Bland-Altman method[1,2] was directed at the primary outcome measure, which was the agreement of the capillary blood lactate level measured by handheld lactate analyser when compared with the reference standard technique. Due to the diverse spectrum of patients seen in the ED, the range of lactate levels was representative of our daily clinical practice and was thus pragmatic. Furthermore, our sample size of 240 was larger than previous studies [3-7] ranging from 24 to 120 patients.

    Lastly, we chose to use a cut off of 2 mmol/L as this is the upper limit of a normal lactate value. As we mentioned in the paper, screening ED venous lactate levels using a handheld analyser could provide information to shorten the time to identify patients at risk and to allow rap...

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  • Request for more granular data

    I commend the authors for developing and validating this proficiency-based progression training. Epidural failures have a significant impact on patient satisfaction and at times patient safety on labor and delivery. The reduction in epidural failure realized through this program is impressive. I wonder if the authors could provide information on each trainees epidural failure rate. There is significant variance in the number of epidural placements that it takes for a trainee to achieve competence. I worry that one or two trainees in the simulation-only group with very high rates of epidural failure may have biased the results significantly. Seeing the epidural failure rates for each individual trainee would address this concern.