1326 e-Letters

  • The absence of basic but vital information makes this paper uninterpretable and unpublishable

    This article is dependent on random sampling of non-randomly ordered lists. Despite this it fails to even mention what random sampling method was selected nor what software was used to implement this method. The list of "randomly" selected signatories generated by this unnamed method is not given in the article itself, however the data availability statement refers to a "public, open access repository" although the repository is not named and no link is given, so perhaps this is available somewhere?

    No sample size calculation is given, and the selection of 30 is not justified within the method or discussion in any way.

    This paper frankly fails to meet minimum standards in describing how the research was actually conducted.

    It is unclear to me what merits of the paper led to its selection for publication, although this lack of clarity is partially driven by the failure of BMJ Open to publish any reviews in violation of their stated policies.

  • Improving the Report of the Buildling Blocks 2-6 study

    In many ways, the Building Blocks (BB2-6) study reported recently in BMJ Open is conducted impressively.1 The depth of analysis of social-service and child-protective-system involvement of families enrolled in Usual Care (UC) and Family-Nurse Partnership (FNP - as the program is called in the UK) is remarkably thorough. I was disappointed, however, to find that the report did not address a number of critical issues as thoroughly as needed to better interpret its findings.
    The most fundamental challenge with this trial is that it was “open-label.” Treatment assignment was not masked to UC providers, including Midwives and Health Visitors (HV) charged with serving the same population as FNP nurses - and with similar goals. This type of design has been criticized because it can lead to “Compensatory Equalization.” 2 I understand why this design was chosen, but am concerned that it compromised the estimate of real FNP effects. Its consequences need to be examined in greater depth.
    In the 18 trial sites, FNP nurses assumed the role of Health Visitors,3 which would allow usual HV’s to serve others on their caseloads more intensively, a condition possibly amplified if they felt, quite naturally, that their service might be devalued if maternal and child health were improved more with visits by FNP nurses. To what degree did this knowledge modify their delivery of UC? The authors have examined this issue, but more can be done.
    Note that the number of visit...

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  • Ethical, Conceptual, Statistical, and Presentational Issues

    This paper has several ethical, conceptual, statistical, and presentational issues. From an ethical standpoint, it is somewhat surprising that the author declares no human subjects are involved. Bibliometric data is widely established as public data, and some IRBs hold the same is true of data gathered from public accounts on Twitter (here, follower counts). However, the author explicitly investigates whether named individuals choose to use Twitter by searching for a linked account through google. Decisions about whether or not to use Twitter are reasonably private. There is no reason to believe someone who has chosen not to use Twitter has consented to their presence in a study on social media use. For these reasons review by an IRB seems warranted.

    Other ethical challenges may arise from a failure to disclose the author's well-documented history of interaction (co-authorship, affiliations, debate, etc..) with the named signatories—positive and negative. An IRB may have taken those relationships into consideration when deciding (for instance) whether it was appropriate to explicitly name scientists. Alternatively, reviewers and readers alike may have found these important context when interpreting the paper as a whole.

    Conceptually, the author acknowledges the limitation that: “​​Both citation indices and Twitter followers have limitations in face validity and construct validity as measures of impact.” Yet the paper’s conclusions are based entirely...

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    Though not patently exhibited or openly expressed, the family of each of these healthcare workers exerts a strong influence on the day-to-day mental health status of their family member. Appreciation needs to be focused on the corollary too. The mental health of all the family members play a role.

    The silent pillars need plenty of support!

  • Clinical effectiveness and bacteriological eradication of three different Short-Course antibiotic regimens and single-dose Fosfomycin for uncomplicated lower Urinary Tract infections in adult women (SCOUT study): study protocol for a randomised clinical

    We applaud the authors for publishing their trial protocol for this important subject of empirical antibiotic approaches in uncomplicated LUTIs in women.

    It is alarming that in the community settings, women presenting with LUTs more than half of the E.coli isolates and more than a third of K. pneumoniae isolates are were resistant to third generation cephalosporins ( i.e.ESBL-producing microorganisms) (1). It therefore makes sense to use Fosfomycin as empirical treatments when >20% of isolates are multi-drug resistant microorganisms (2), What is not clear is why GPs in Spain prefer to use short-course therapies over single-dose therapy which is not in line with the Spanish national guidelines. We believe that better compliance could be achieved in addition to desirable outcomes with this strategic approach although as the authours mention there may potentially be more relapses. It would be useful to explore what the reasoning is behind this preference. Perhaps, they have concerns regarding the pharmacokinetic and spectrum of activity of Fosfomycin (3) that might not achieve the desired clearance of microorganisms? This has clearly been described elsewhere including a comprehensive metanalysis on the successful outcomes of single dose Fosfomycin (4-6). Indeed, we read with interest that you hypothesise that short-course treatments will be more effective than the recommended 3 g single dose of Fosfomycin, resembling what clinicians usually do in routine practice....

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  • Authors’ response to 'Pacing: one term, many meanings'

    The activity pacing framework was developed to address a clinical need to provide a comprehensive guide for healthcare professionals on instructing activity pacing to a range of patients who commonly seek assistance in the management of symptoms of chronic pain and fatigue. As a research team with clinical and academic backgrounds, we see many patients seeking healthcare services presenting with overlapping symptoms and co-existence of conditions of chronic pain and fatigue, including chronic low back pain, chronic widespread pain, fibromyalgia and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). In the current study, co-morbidity of chronic conditions was evident. At baseline, 65 participants (61.3%) reported two or more conditions of chronic pain or fatigue. Observing specifically the subgroup of participants with ME/CFS, 11 of the 12 patients with ME/CFS reported least one other co-morbidity of either low back pain, chronic widespread pain, fibromyalgia or another condition. Ten of these 12 patients reported ME/CFS to be their main condition. This clinical presentation of overlapping symptoms and co-existence of chronic pain and fatigue is recognised in the research literature [1, 2]. As such, our work into activity pacing has had an inclusive approach for patients with a range of symptoms, and for healthcare professionals working across varying services.

    In reference to our earlier work to develop an activity pacing questionnaire, Michiel Tack has q...

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  • Re: Trends in acid suppressant drug prescriptions in primary care in the UK

    Abrahami et al. examined proton pump inhibitor (PPI) and histamine-2 receptor antagonist (H2RA) prescribing patterns over a long period in primary care in the UK (1). From 1990 to 2018, PPI prevalence increased from 0.2% to 14.2%, while H2RA prevalence were under 3.4%. The authors described that PPIs were associated with a number of adverse effects not attributed to H2RAs, and recommended H2RAs as a valuable treatment as acid suppressants. I have a comment about the study with special reference to dementia risk.

    Prescribing acid suppressants is more prevalent in the elderly. Wang et al. conducted a meta-analysis to investigate the risk of acid suppressants on dementia (2). The pooled adjusted hazard ratios (95% confidence intervals) of PPI users and H2RA users for the development of dementia were 0.98 (0.85-1.13) and 1.20 (0.98-1.47), respectively. Although there is no significant association regarding the effect of acid suppressants on the development of dementia, H2RA presented a trend of increased risk for dementia. There are medical reasons of prescribing PPIs instead of H2RAs, and evidence should be presented for concluding the higher adverse effects of PPIs than H2RAs.

    1. Abrahami D, McDonald EG, Schnitzer M, et al. Trends in acid suppressant drug prescriptions in primary care in the UK: a population-based cross-sectional study. BMJ Open 2020;10(12):e041529.
    2. Wang H, Tian L, Yan X. No association between acid suppressant use and...

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  • Copd Remedy

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  • Pacing: one term, many meanings

    The version of pacing proposed by Antcliff and colleagues for patients with chronic pain and fatigue contradicts how the term is applied in the myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) community.

    Jamieson-Lega et al. previously noted that pacing represents “a variety of differing and, at times, contradictory concepts.” (1) Broadly, two main traditions exist. One has a history in operant conditioning and is mostly used in the treatment of chronic pain. It consists of a preplanned strategy that is time- or quota-contingent with the aim of breaking the association between resting behavior and symptoms. It involves dividing tasks into manageable parts, doing things slowly but steadily, and building a consistent routine to achieve a target, often an increase in (physical) activity. (2) The other main tradition is energy conservation management as used in patients with neurological conditions such as multiple sclerosis. Here, pacing can be symptom contingent as it is mainly aimed at avoiding overexertion and relapses while engaging in meaningful activities. It involves balancing activity and rest, delegating tasks, setting priorities, and using assistive devices. (3)

    The “activity pacing framework” developed by Antcliff and colleagues is in line with the first tradition but ignores the second. It follows principles of quota-contingency and focuses on gradually increasing activity levels. It is presented as a rehabilitative intervention provided b...

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  • Professor

    The conclusion states "The considerable number of included papers reporting a statistically insignificant result decreases the usual concern over publication bias". I disagree with this. Firstly, the number of p-values labeled "non significant" in Table 3 was 15 out of 48 (31%), which I would not call "considerable". More importantly, if nudges are not effective then there should be many negative studies, so there still could be a large publication bias. Searching for registered studies that used a nudge but were never published would give some evidence of potential publication bias.