545 e-Letters

published between 2014 and 2017

  • Response to Vibha Jaiswal, Barriers to real world deployment of HPV consultation guides by ENT surgeons

    On behalf of the authors: We thank Dr Jaiswal for her generous and supportive comments about our article, ‘Talking about human papillomavirus and cancer: development of consultation guides through lay and professional stakeholder coproduction using qualitative, quantitative and secondary data’. We are pleased that reading it prompted her to conduct a rapid assessment of our consultation guides.
    We were delighted to discover the close similarities between the comments expressed by the clinicians in our study and the doctors who took part in Dr Jaiswal’s assessment exercise, and gratified that they found the consultation guides useful and would give the information leaflets to their patients. That the number of doctors fairly or very confident discussing HPV in the context of a Head and Neck consultation rose from 56% to 100% is very encouraging. This further strengthens our confidence in these tools. We would be pleased to receive continuing feedback from clinicians on their use of the guides or the patient information leaflets.
    The main barriers to deployment of the consultation guides in the real world are the practical ones of dissemination and implementation. How can we inform the appropriate clinicians of their existence, and make these resources more easily accessible to them? At present they are available to download; we would like to see them produced as print versions that could be more readily to hand in a consultation. We also believe that the...

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  • Comment on statistics

    Poisson regression is unsuitable for analysing data from Likert scales, even in aggregate (see http://rcompanion.org/handbook/E_01.html).

    Summing enough Likert scales (as when summing enough random variables) might result in summary data which are suitable for least squares regression, via the central limit theorem. But, Poisson regression is suitable for count data where the variance is equal to the mean (count data that violate this equality may require negative binomial regression).

    Since the statistical analysis is inappropriate, the Results and Conclusions may be unsound.

    Multi-level IRT is probably an appropriate way to analyse multiple Likert scales (e.g. Luo & Wang, Stat Med. 2014 Oct 30; 33(24): 4279–4291)

  • Important issues for casualty trauma care and an ethical plea

    The authors accomplish to objectify the experiences of military surgeons collected in current military conflicts by this scientific study and manage to give practical guidelines for the treatment of the sustained injuries.

    Especially the significance of multiple amputations and perineal injuries as indicators of more severe injuries (e.g. pelvic fractures) due to a massive transfer of energy is highlighted. These patients are at a higher risk of exsanguination and infection. First important measures can be applied in the field by the attending medic: the liberal use of tourniquets and pelvic binders cannot be stressed enough. A finding that even has impact on the civilian sector. With an increase of terroristic attacks we can implement the knowledge which was won in military conflicts.

    Moreover we may not neglect the effects of these injuries onto the whole life of the patients which are mostly young men. A lot of subsequent problems have to be expected that represent major challenges for both the patients and the societies. Especially as a result of ageing many patients will compensate their lost limbs to a lesser extent over time.

    Beyond the medical findings this paper stands out especially because of its ethical assessment of AP-IED’s. It was utterly justified to outlaw the use of APM’s, in today’s conflicts APM’s only play a minor role. A similar process concerning the AP-IED’s is extremely desirable which even have more gruesome effects as shown...

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  • Amendment to the OPTIMUM Protocol

    To the editor

    We would like to notify readers of two amendments that have been made to the OPTIMUM trial protocol since its publication in the BMJ Open in October 2016. These have been approved by the Regional Ethics Committee (Brighton and Sussex - 15/LO/1018)

    1) Indwelling Pleural Catheter Pathway: On the day follow-up 4 for the indwelling pleural catheter group, the criteria of <150ml/day fluid output to administer talc has been removed as complete drainage on day 1 may be limited due to symptoms.

    2) Set up of international sites: For international sites (defined as outside of the UK), the trial pathway will remain the same. To ensure satisfactory trial conduct and accurate data capture, the OPTIMUM database will be contained on a web-based browser-accessible database. This password protected, secure database service will only be accessible to the trial team at GSTT as well as the satellite international sites.

    User policies (with unique logins) will be implemented to prevent unauthorised data manipulation and access to data outside of the institutions recruited and a full GCP compliant audit trail will be used to monitor activity.

    Yours Sincerely

    Dr Parthipan Sivakumar & Dr Liju Ahmed

  • Thanks for your Comments related to International Humanitarian Law

    Thanks for your comments and I agree it is difficult to address Rule 70 in countries who do not subscribe to the conventions. However this does not negate the need for continued efforts to add AP-IEDs to the list of weapons that cause excessive injury or suffering that is disproportionate to the military advantage sought by their use, and only by only by documenting and publishing these injury patterns can we offer the necessary evidence. The data also suggests the indiscriminate nature of this weapon - in that children were part of the co-hort – and this also needed to be identified.

  • International Humanitarian Law: Rule 70

    The authors of this article claim that they document this weapon to cause "superfluous injury and unnecessary suffering". This is terminology that refers to International Humanitarian Law. The International Committee of the Red Cross have catalogued these laws. Rule 70 states that "the use of means and methods of warfare which are of a nature to cause superfluous injury or unnecessary suffering is prohibited."(1) Some would say that there is no point to pursuing this legal angle because those who use IEDs tend not to be among those who sign on to the Geneva conventions. However International Humanitarian Law is considered to be customary and therefore applicable to every human being regardless of the law, or absence of law, in their own country.

    (1) https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule70

  • Barriers to real world deployment of HPV consultation guides by ENT surgeons

    I commend the authors on publishing, and, thank the patients who participated, in this exhaustive study of a difficult topic which covers taboo areas in society. As the authors note, talking about HPV in head and neck cancer is not comfortable for clinicians, with one using the phrase “a can of worms”. Interestingly although most patients were surprised and shocked that HPV caused their cancer, they found the information given in the study context and consultation guides reassuring.

    The one disappointing aspect of the study was the low clinician feedback (47%) on the eventual consultation guides produced (17 out of 36 clinicans responded). Anecdotally there remained concerns amongst the ENT surgeons who had contributed to the study that Head and Neck cancer patients would not want to know or were not interested in the HPV aspect as it was rarely brought up in consultations.

    Therefore I conducted a short and rapid assessment to assess the response to the published consultation guides amongst younger ENT surgeons (core trainee to consultant surgeons working all over Wales.

    Two questionnaires (A) and (B) were completed by ENT surgeons before and after reading the consultation guides (for clinicians and patients) produced by Hendry M et al. BMJ 2017 doi: 10.1136/ bmjopen-2016-015413. Questionnaires A and B asked about respondents’ current practice and confidence in handling such consultations completed before (A) and after (B) reading the leaflets....

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  • RE: Epistemonikos: A database not to be missed while searching systematic reviews

    The authors would like to thank Dr. Singh and colleagues for their positive comment on the findings of the review. Dr. Singh and colleagues correctly point out that an eligible review[1] was not included in our comprehensive set of systematic reviews on non-pharmacological interventions to treat behavioural disturbances in older patients with dementia[2].
    We revised our search archive and find out that the review was indeed identified from all the four electronic databases (MEDLINE, the Cochrane Library, CINAHL and PsychINFO) that generated 4 duplicates that were all erroneously deleted. We apologize to the readers for this error.
    After retrieving the review, we assessed it according to the methodology described in our original paper[2]. The review by Kong et al. (AMSTAR 6) identified 14 studies (with overall 586 participants) published between 1998 and 2003. All were randomised trials, seven of which had a cross-over design. Five of the trials [3-7] were already included in other systematic reviews identified in our original manuscript.
    The remaining studies investigated thermal bath (15 participants) [8]; platform style rocking chairs (25 participants) [9]; therapeutic recreation activities (10 participants)[10]; individualized recreational therapy interventions (29 participants)[11]; bright light therapy (8 participants)[12]; educational program on delivering abilities-focused morning care (40 participants)[13]; "stimulation-retreat" model...

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  • Combination therapy lacks sound evidence to be recommended as initial choice

    Dear Editor:

    Dr. Weir and colleagues regret in their article (1) the ‘conservative’ approach adopted by NICE, by favouring initiation of antihypertensive monotherapy no matter the basal hypertension severity (2). Thus, based on their results, the authors state that a combination therapy might be envisaged “for patients with grade 2 or 3 hypertension or high normal/grade 1 hypertension plus at least one cardiovascular condition”.
    Reliable information from observational studies, as is the case of the present cohort study, is always welcome. However, even more attention should be paid to direct comparisons from well-designed clinical trials. In this regard, a Cochrane systematic review published in January 2017 shows the best available evidence on this topic (3). Unfortunately, there is no mention to this review in the ‘Discussion’ section of Dr. Weir’s article.

    According to this review, only subgroups of participants from three studies (monotherapy: 335 participants; combination therapy: 233 participants) met the pre-defined inclusion criteria. The certainty of evidence was judged very low due to the insufficient number of participants and events. Thereby, large clinical trials are needed in order to decide which strategy, monotherapy or combination, should be adopted by doctors in different clinical situations. In the meantime, a ‘conservative’ approach represented by the ‘monotherapy’ alternative is probably the wiser recommendation we can make.

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  • Re: Letter to the Editor – The INTERMED as a complexity assessment and intervention tool

    Stiefel et al. presented much evidence concerning INTERMED. In addition to this, they presented a self-assessment version of the INTERMED (the IMSA). Indeed, INTERMED is an established tool for assessing complexity.

    The correlation between PCAM and INTERMED was shown in our article. Spearman’s rank correlation coefficient between these scores was 0.90, which indicates a strong correlation. This shows the possibility of using PCAM as a substitute for INTERMED.

    However, we recognize that INTERMED does not have obvious evidence in primary care because there are no published articles. In addition to this, Stiefel et al. pointed out the time issue for physicians. Time saving is not only useful for physicians but also other medical professions. The shortage and burnout of medical professions, including nurses, are problems in Japan and other countries[1-4]. If time for assessing anything can be saved appropriately, we think reasonably. As Stiefel et al. mentioned, another solution to resolve the time shortage is the self-administered version such as the IMSA; however, no self-administered test for measuring complexity exists in Japanese.

    We plan to study the relationships between the patient complexity and the burden of medical professions. To recognize PCAM as an established and feasible tool, many studies about PCAM are needed in future. We are glad to discuss the complexity. This concept is not major in Japan. We hope that the complexity will become to be...

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