124 e-Letters

  • Letter to the editor

    Dear Editor,
    This response is in relation to the titled article above published in June 2019. Firstly, I would like to commend the outstanding work of research done. While reading the article, I understood the correlation between the nursing field, evidence-based research, and ways in which patients benefit from current health practices. Furthermore, the research conducted a wide range of research benefits in other nursing career paths globally. It showed experts views on teaching evidenced based prospectus, evidence-based deliberations, and stakeholders’ engagement which can impact patients involved. I agree with the study conducted and how research is essential for future advancements as well as improvements in care to patients. Unfortunately, there aren’t as much published research work in The Bahamas on evidence-based practices from an expert view. Through further research this thesis can become widespread to obtain more views on this pressing matter.

  • Letter to the editor

    Dear Editor:

    My name is Student Nurse Montel Stuart. from the University of the Bahamas. I have read your article and found the area of research to be very interesting and encourage to you to further your research on the effect of counselling on uninsured patients.
    Montel Stuart

  • RE: Lack of effects of evidence-based, individualised counselling on medication use in insured patients with mild hypertension in China: a randomised controlled trial

    Dr. Terry Campbell, a lecturer at the university's School of Nursing

    This is a response to the article that was published on August 31, 2019, which can be seen above. The article was quite fascinating to read since it focuses on hypertension and how the therapy would effect medication usage in insured individuals; however, the study that was offered was based on a review of the healthcare system in China's population. After reading this study, I have come to the conclusion that it is essential to supply patients with information that is pertinent to their conditions and to take into account the patients' values in the process of making clinical decisions. Doing so can boost patient participation and contribute to the development of patient-centered, individualized care. The researcher provided individual counseling and found that the rate of willingness to pay completely out of pocket for antihypertensive drugs dropped significantly after evidence- based individualised counselling; however, it is uncertain whether that evidence- based, individualised counselling regarding hypertension and its treatment would actually impact medication use in insured patients with mild hypertension.
    The findings of this research are restricted in a few important ways. To begin, it may be affected by reporting bias, which is a typical worry in data that is self-reported. This bias may occur when people lie about what they did. Prescription refills, patients'...

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  • Claims about the main claim

    Title: “Claims about the main claim”
    Author: Suhail A, Doi, Polychronis, Kostoulas, Paul, Glasziou
    In response to the published article "Likelihood ratio interpretation of the relative risk"

    Rapid response :
    September 16, 2022

    The problem in evidence-based medicine arises when we port relative risks derived from one study to settings with different baseline risks. For example, a baseline risk of 0.2 and treated risk of 0.4 for an event in a trial gives a RR of 2 (0.4/0.2) and the complementary cRR of 0.75 (0.6/0.8). Thus the ratio of LRs (RR/cRR) is 2/0.75 = 2.67. If applied to a baseline risk of 0.5 the predicted risk under treatment with the RR “interpretation” is 1.0 but with the ratio of LRs “interpretation” is 0.73. Here, the interpretation of the risk ratio as a likelihood ratio, using Bayes’ theorem, clearly gives different results, and solves the problem of impossible risks as clearly depicted in the manuscript and the example.
    If, in our effort to highlight the need of this correct interpretation, we have used strong wording that annoyed the commentator we feel the need to express regret. We hope that the commentator could also feel similarly for his scientifically unbecoming choice of wording that culminated with “Doi’s Conjecture”.
    Conflict of Interest
    None declared

  • The main claim in this paper is not even wrong

    Dear Prof. Franco,

    I am writing to request further clarification on the paper “Likelihood ratio interpretation of the relative risk”. The “key messages” section of this paper states that the study adds the following to the literature:

    ⇒ It is demonstrated that the conventional interpretation of the relative risk is in conflict with Bayes’ theorem.
    ⇒ The interpretation of the relative risk as a likelihood ratio connecting prior (unconditional) intervention risk to outcome conditional intervention risk is required to avoid conflict with Bayes’ Theorem

    I will refer to the first bullet point as “Doi’s Conjecture”. Doi’s Conjecture is also stated in the second section of the main text, where it is claimed that “the usual interpretation (33% increase in the +ve outcome under treatment) contravenes Bayes Theorem”.

    No attempt is made within the text to prove Doi’s Conjecture. But perhaps more worryingly, no attempt is made to define the term “interpretation”, a term which is not defined in standard probability theory. The meaning of Doi’s Conjecture is therefore at best ambiguous. Moreover, the manuscript relies substantially on claims about how effect measures are “perceived”, another term which is defined neither in probability theory not in the manuscript.

    The relative risk is defined as the risk of the outcome under treatment, divided by the risk of the outcome under the control condition; that is, as a ratio of two probabilities. Thi...

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  • Equipoise, or not, when comparing filtering face piece respirators to surgical (medical) masks, and the futility of using a randomized control trial (RCT) for comparison. The need for evidence-based medicine+ - a paradigm shift.

    Airborne transmission and inhalation, of SARS-CoV-2 is recognized by international public health agencies (Addleman et al. 2021) from both short- and long-range aerosol transmission (Tang et al. 2021).
    When comparing filtering face piece (FFP) respirators, with a surgical (medical) masks, for protection against an inhalable (ISO 7708) airborne virus such as SARS-CoV-2, “EQUIPOISE” a central tenet for conducting a randomised control trial (RCT), does not exist. The futility of using a RCT is analogous to carrying out a study in a construction site for hard hats or seat belts in a passenger vehicle. FFP respirators used in Canada are selected and used in accordance with CAN/CSA-Z94.4-18 (Selection, use, and care of respirators). Specifications are provided in CSA Z94.4.1:21 (Performance of filtering respirators).
    At least two international studies using RCT have been initiated since the start of the COVID-19 pandemic.
    a) United Kingdom: The impact of different grades of respiratory protective equipment on sickness absence due to respiratory infections including SARS-CoV-2 for healthcare workers (The funding committee did not recommend funding).
    b) Canada, multi-centre: where nurses are randomized to either use of a medical mask or to a fit-tested N95 respirator when providing care for patients with febrile respiratory illness.
    The findings from a poorly designed RCT may also be used as improper and biased rationale to downgrade respirator (masks...

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  • EBM+ or a Trojan horse of 'science-experts'

    The clinical evidence we produce which impacts the care we deliver to patients must have the highest standards. Unlike biomedical evidence, the evidence behind our treatments, risk factors and diagnostic tests should be relevant to the patients and clinicians who practice at the coal-face and real-world of General Practice and our hospitals.
    We may have had 250,000 'peer-reviewed' articles relating to COVID-19 (whatever credibility that affords), but allowing biomedical assumptions to creep into guidelines and direct patient care, is taking a step backwards in evidence-based practice. COVID saw a multitude of 'experts' give their opinion freely in the media and on social media platforms, based on biomedical ‘evidence’, on opinion, through the platforming of academic-status and on dubious case-studies. This was self-evidently un-scientific, and arguably has set science back. Yet this article seems to advance the notion that this evidence should impact patient care.
    So much has to be done to enable EBM to flourish- yet this article will likely set EBM back. The evidence underpinning our treatments should be quantifiable in absolute terms, and the uncertainties and conflicts of interests (COIs) acknowledged. The evidence behind our risk factors characterised in absolute terms, within the context of confounders and biases from observational studies. Our diagnostic tests should be understood within the context of odds and post-test probability. O...

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  • EBM orthodoxy has had a quasi-religious feel to it.

    This refreshing article does much to help move forward from the self-imposed strictures of the EBM orthodoxy. I hope EBM+ grows as an idea as, currently, EBM feels, sometimes, quasi-religious in the fervour to reject “the wrong sort” of evidence. It leaves clinicians in fields like addiction - where RCTs are very difficult to do unless so simple in their structure that the results are clinically difficult to use or, worse, irrelevant - stuck. Meta-analyses of clinically irrelevant studies are still clinically irrelevant. Data is hard to come by that is not EBM-perfect, so why bother doing the clinical research? Hopefully this suggestion will improve that disconnect.

  • In Memoriam Ingeborg Griffioen

    To our great sadness on Wednesday, April 13th 2022, Ingeborg Griffioen, author of “Innovating in healthcare: perspective from a dual role” passed away, at the age of 50. She departed with acceptance of the inevitable and in connection to those she loved and who loved her.

    Ingeborg was founder and owner of Panton design studio, specialized in healthcare. In 2016 she started a PhD research on the use of service design to support shared decision making. Less than one year later, her husband was diagnosed with pancreatic cancer. Ingeborg incorporated their experiences with his care trajectory in her research, which led to the development of MetroMapping, a method to support shared decision making (www.metromapping.org/en). During this development process, Ingeborg herself was diagnosed with breast cancer.

    It was one of Ingeborg’s dreams that MetroMapping be further developed and implemented at a large scale. Even during her chemotherapy she contributed to the 4D PICTURE project proposal, which focuses on adapting, evaluating and implementing MetroMapping in hospitals throughout Europe. Early 2022, we received the news that Ingeborg’s dream will come true, as 4D PICTURE was selected for funding by Horizon Europe. Ingeborg wrote a beautiful testimonial for 4D PICTURE:

    “As a designer I have worked for 25 years in healthcare settings and as a researcher I studied treatment decision-making. I know the importance of...

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  • Plausibility bias

    The article by Gartlehner et al. [1] is interesting because it allows the homeopathic community to elaborate on potential publication bias in clinical trials of homeopathy. There are, however, several questionable elements: in the article, and in the announcement made on the BMJ web, it is concluded that there was a high proportion of trials not preregistered, but at the same time Gartlehner acknowledges in the press that over time there has been a substantial improvement in the preregistration of trials [2]; it is mentioned that homeopaths must improve, but at the same time it is implied that "homeopathy cannot work".
    On the second point, it is worth mentioning that in the article Gartlehner et al cite two trials, one by Grimes [3] and the other by Grams [4]. These essays are based on a biased selection of literature and have elementary errors. For example, Grimes says that Jacques Benveniste's famous study was published in "1987" and that Madaleine Ennis' work was negative when in fact it was positive [5]. Grimes bases his conclusions on theoretical claims (a simple calculation of Avogadro's constant) and not on experimental studies that at the time were available (e.g. [6]). Grams, on the other hand, only cites some old articles from 1992 and 1993 without mentioning more recent studies (e.g. [7]).

    1. Gartlehner G, Emprechtinger E, Hackl M, Gartlehner J, Nonninger J, et al. (2022). Assessing the magnitude...

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