1537 e-Letters

  • Updated protocol in response to Covid-19 government restrictions

    This update relates to the study protocol for “Can a teacher-led mindfulness intervention for new school entrants improve child outcomes? Protocol for a school cluster randomised controlled trial”

    Mindfulness-based approaches have been shown to be effective in improving the outcomes for adults, with emerging evidence for adolescents and children. However, the majority of these interventions have not been evaluated through controlled trials to understand their effectiveness and cost-effectiveness. Furthermore, fewer studies have examined mindfulness intervention using play-based activities and targeting teacher practice to ensure practices are sustained over time. To address this gap, the design was a cluster randomised controlled trial in primary schools (clusters), with schools randomised to either the Minds@Play intervention or ‘business as usual (control). This study aims to contribute to the evidence related to the effectiveness and cost-effectiveness of whether a mindfulness intervention is able to provide outcomes for students, and the implementation factors which may influence the outcomes observed.

    Several changes to the original study protocol were made to reflect learnings from the set up and conduct of the study, as well as reflect the government-mandated restrictions in Melbourne, Victoria, where the study was conducted.

    In Melbourne, Australia – where the study was based – there were a numbe...

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  • Cardiac assessment in systemic sclerosis

    In the meta-analysis and systematic review by Qiao et al regarding the assessment of cardiac involvement in systemic sclerosis (SSc) using speckle tracking echocardiography the authors have reported that left ventricular (LV) global longitudinal strain (GLS) is lower in SSc patients than in healthy control subjects 1. While not specifically stated by the authors, it could possibly be concluded from this finding that there is now evidence to support performance of GLS during the screening of SSc patients and the use of this GLS result for early diagnosis of myocardial involvement. However, there are a number of reasons why such a conclusion should be considered premature. (1) There remain significant discrepancies in the literature with respect to the effect of SSc on GLS which require explanation but have not been explained by this meta-analysis. Moreover, errors have been made in study selection, with one particularly concerning error being that one of the included studies is actually a study of multiple sclerosis, not systemic sclerosis 2. A further error is that one of the other included studies reported a standard deviation (SD) of GLS of 8.9% in the control group, a very large number which suggests substantial errors of GLS measurement in this group and should therefore have invalidated its inclusion 3. (2) In healthy subjects the absolute value of GLS decreases with age and is higher in females 4. This is of particular importance for any study of SSc given that patie...

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  • Reply to: A Robust Statistical Approach Increases the Reliability of the Findings

    Dear Dr. Majidi,

    Thank you for your interest in our research and acknowledgment of its importance for the general population and healthcare systems. We appreciate your attention to the methods we chose for conducting the upcoming meta-analysis.

    After careful consideration of your suggestions to revise a threshold for the I2 test, we agree that elimination of the 75% cut-off is suitable for addressing the first specific objective, which is to calculate the prevalence of sexual dysfunctions. The second specific objective is to find out the relationship between breast feeding types and sexual dysfunctions. To measure reliably the effect of particular feeding types on the likelihood of sexual dysfunction, we should analyze studies with matching cohorts and time since delivery. For high credibility of study findings, we will adhere to the common rule of assessing between-study heterogeneity and maintain a 75% threshold for the I2 index.

    In the “Study design and data source” section we highlighted the inclusion of peer-reviewed papers in the meta-analysis. However, recent studies advocate for necessity to cover grey literature and, in particular, official reports (1). Therefore, we decided to search for reports from local and international organizations. A method proposed by Naing et al. for an official national survey is not suggested by JBI (2)(3). We will consider this technique for critical appraisal of prevalence studies rather than for sensitivity...

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  • IMGs: supporting a growing workforce

    We sincerely thank Al-Haddad for their interest and support of our article (Healey SJR, Fakes K, Nair BR. Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review. BMJ Open 2023;13:e071992.)

    At the time of writing, we were able to only access GMC data from 2020 (The changing medical workforce. General medical council [PDF]. 2020. P103. Available: https://www.gmc-uk.org/-/media/documents/somep-2020_pdf-84684244.pdf), which estimates the combined EEA (European Economic Area) and IMG (International Medical Graduate) figure at about 36%. Increased numbers of IMGs (including EEA) over more recent years, in the new data Al-Haddad has cited, calls for even greater need to better explore and action the needs and challenges faced by all IMGs in the UK and indeed across the world. We strongly support further study into this much needed area.

  • 'Maze' not pathway: the role of technology

    Dear Editor
    I read with interest the paper by Jasim and co-authors that described a focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway. (1)

    The results were interesting – especially when the patient journey was described as a maze rather than a pathway. Even though the number of participants was small, the message was clear: there was a lack of patient-centredness to the pathway.

    However, a greater issue is if anything can be done about the problem. In the future, it is likely that all care pathways will be electronic. Thus, it is tempting to believe that technological advances will enable the pathway to be much more personalised to the needs of individual patients.

    In the future, could pathways automatically start where patients are rather than where the system assumes they should? Could pathways automatically and immediately tell patients where they are in their journey so that they are fully informed in real time? Could pathways enable patients to get to their destination by the quickest possible route?

    Technology would also allow healthcare providers to continually track patients along different pathways. Doctors would see where patients might have been blocked and where some might have stepped off the pathway. This could potentially happen with all patients so the number of participants analysed would be far higher and results far more reliable.

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  • A comprehensive surveillance system for recording suicides and attempted suicides – How feasible in India?

    The study could capture sensible data, which is known to be notoriously difficult to acquire. But the study fails to achieve its primary objective, which is the feasibility of community surveillance for assessing suicides and attempt suicides. It only answers the second objective: added benefits of community surveillance to hospital and police records.
    India is often referred to as a ‘nation within nations’ and such community interventions studied in a specific area (2 districts in the state of Gujarat) cannot be generalised for the Nation, but further multicentric studies will help in better understanding.
    The study recruited a good number of informants (833), 13% of them dropped out of the study. Even after recruiting such a huge number, 42(36%) attempted suicides and 26 (30%) suicides had only a single informer, which is not ideal for the validity of the results. This also shows if community surveillance has to be implemented, it will require huge manpower at the community level to support the same.
    The researchers employed data triangulation by comparing information from hospital records, police records, and data obtained through community surveillance. This approach not only increased the study's validity but also uncovered 55 (63%) suicide cases that had not been documented elsewhere, highlighting the limitations of existing systems. However, it is crucial to acknowledge that a quarter of the hospitals(13 out of 53) in the area did not contribu...

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  • Who is an International Medical Graduate (IMG)?

    I read with interest the article titled ‘Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review’ by Healey, Fakes and Nair.[1] The authors present their findings on an important issue that affects IMGs worldwide. In the introduction, the authors point out that 1:3 of doctors in the UK are foreign-trained. This proportion is not accurate and stems from confusion about who an IMG is, and how the General Medical Council (GMC) in the UK presents data on IMGs.

    An IMG is a doctor who practices medicine in a country different to their country of primary medical qualification (PMQ)[2]; a definition which Healey and colleagues agree with and use for their scoping review.[1] The understandable confusion arises when they and other authors quote figures on the proportion of IMGs in the UK and refer to publications from the GMC. The GMC’s definition of an ‘IMG’ is a doctor whose country of PMQ is outside Europe and practices medicine in the UK.[3] The GMC uses this definition for practical reasons as the process of registering for a license to practice in the UK for doctors whose country of PMQ is within Europe is different to doctors whose country of PMQ is outside Europe.[4] The GMC register in August 2023 showed that the proportion of ‘IMGs’ by the GMC’s definition was indeed 32.5% (i.e., 1:3). However, the proportion of doctors whose PMQ was from Europe was 10%. Therefore, the true proportion of IMGs in the UK is 42.5%.


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  • A Robust Statistical Approach Increases the Reliability of the Findings

    Dear BMJ Open,
    Having perused the article titled "A Protocol for a Systematic Review and Meta-analysis Investigating the Risk of Sexual Dysfunctions in Breastfeeding Females," I found it captivating and of great significance to the general population. The notion behind this study is innovative, as it tackles the concerns of numerous patients who worry about potential sexual disturbances during breastfeeding. I firmly believe that this article will provide invaluable insights into a topic that greatly interests a wide audience.
    Given my keen interest in this study, and with the aim of enhancing its quality and the reliability of the final findings, I would like to offer a few suggestions.
    Firstly, the authors mention their intent to perform a meta-analysis only if the heterogeneity index falls below 75% (I2 ≤ 75%). As you are well aware, prevalence studies often exhibit substantial residual heterogeneity. Such heterogeneity is inherent in the nature of these studies and has been deemed acceptable within the existing literature (1, 2). In fact, many high-quality prevalence meta-analyses have reported I2 values exceeding 90% and even 99%, despite attempts to mitigate heterogeneity through techniques like subgroup analyses (3-6). Therefore, I contend that imposing strict eligibility criteria for inclusion in the meta-analyses would be ill-suited for this study, as it is expected to encompass numerous situations with high I2 values. Excluding a signi...

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  • Bismuth treatment of C. difficile enteritis

    Dear sirs,
    Practically all therapeutic modalities for the treatment of C. difficile enteritis have one thing in common. They are hugely expensive limiting their use even in affluent societies. Alanyl-glutamine is an exciting approach, as it is a relatively simple molecule, and may therefore be cheaper.
    A very old treatment tool exists however, that has been very rarely studied or used in recent years: bismuth. There is data that it is effective in C. difficile enteritis, has very few negative effects and is dirt cheap. The latter is probably one of the reasons for the lack of motivation for research about it. The use of bismuth salts in treating C. difficile enteritis is something definitely worthy of further study. Besides the 100 plus years of experience with bismuth, no approval or licencing is necessary.
    Yours sincerely
    Z. Lengyel MD, PhD.

  • Updates on the study protocol for the OECD international PaRIS survey and on its implementation (30 June 2023)

    The authors of the study protocol of the OECD International Survey of People Living with Chronic Conditions (PaRIS survey) wish to inform readers about some changes in the study protocol and implementation of the Main Survey.

    Study protocol
    As mentioned in the published article (see Protocol amendments), the study protocol would be modified based on the experiences with and results of the Field Trial. These modifications include:

    1. Calculation of the sample sizes
    Sample sizes for the Main Survey were based on statistical simulations carried out on the data collected in the Field Trial. The simulations were conducted with the data of four main outcome measures: the Physical Health and Mental Health scales of the PROMIS® Scale v1.2 – Global Health, the WHO-5 Wellbeing Index, and the Person-centred Coordinated Care Experience Questionnaire (P3CEQ). The main criterion for determining the sample size was the reliability of country-level estimates for each of the four scales. Given the characteristics of the scales and the clustering within practices and countries, the value of this reliability depends largely on the number of practices per country and the number of patients per practice. The reliability of each scale was simulated for different combinations of numbers of primary care practices and patients per practice. The combination of 100 practices and 75 patients per practice resulted in sufficiently reliable scales (>.70) at country level. Th...

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