eLetters

138 e-Letters

  • “Bad faith” in reporting on homeopathic research

    Gartlehner et al (1) concluded that the effects of homeopathic clinical trials may be overestimated due to publication bias. Such conclusions are inaccurate based on their own statement and their evaluation of the data they investigated. The authors asserted, “the difference in effect sizes between registered and unregistered studies did not reach statistical significance.” Despite this clear statement of what their data showed, the researchers instead came to a different conclusion that sought to question the integrity of research results with homeopathy.

    To their credit, these authors acknowledge that the problem of “non-publication of trial results and selective outcome reporting …. is not a phenomenon that is limited to homeopathy.” And yet, they purposefully chose to not reference any literature that evaluated this problem in publication bias from clinical trails testing conventional medicine. A simple review of the literature would find that conventional medical trials have at least the same rate of publication bias as those reported upon that tested homeopathic medicines (2), to reviews of research that showed a much higher level of publication bias when reporting on conventional medical treatments (3).

    The fact is that several media (4)(5) that have reported on this study have come to the mistaken conclusion that the results of homeopathic clinical trials are not to be trusted, and this biased conclusion stems from the Gartlehner articl...

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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]).

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

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  • 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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  • 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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  • 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.
    Regards,
    Montel Stuart

  • 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.

  • 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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  • 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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  • NICE Response to: NICE rapid guidelines: exploring political influence on guidelines

    In their article McPherson and Speed claim that NICE’s independence seems to have diminished over time, and that it has been significantly undermined during the COVID-19 pandemic. They attempt to explain how various soft political factors may operate and how they undermine NICE’s scientific integrity.

    The authors begin by suggesting that NICE’s re-establishment as a non-departmental public body (NDPB) in 2013 was prompted by the need to “increase the deniability of rationing claims or for other political purposes”.
    Rather surprisingly, the authors then go on to claim that:
    “This revision to the relationship can be regarded as a move towards a more explicit form of meta-governance, whereby government mechanisms are enacted through a range of quasi-autonomous bureaucratic devices.”
    and further that:

    “decisions about access to healthcare, for example, can be made remotely from ministers and political motive obscured by claims of the need for availability to be determined by science, not politics."

    These statements are baffling because the legal position is clear. As a statutory corporation NICE is more, rather than less, independent as an arms length body (ALB) and as a body subject to administrative law and the administrative court, NICE is positively required as a matter of law to reach its decisions independently. If it did not do so its decision would be subject to being overturned by the courts. Furthermore, the regulations...

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  • Rapid Response, BMJ Evidence-Based Medicine

    Rapid Response, BMJ Evidence-Based Medicine
    Re: Popp M, Kranke P, Meybohm P, et al. Evidence on the efficacy of ivermectin for covid-19: another story of apples and oranges. BMJ Evidence-Based Medicine Published Online First: 20 August 2021. doi: 10.1136/bmjebm-2021-111791

    Ivermectin in Covid-19

    Andrew Bryant MSc
    Population Health Sciences Institute, Newcastle University
    Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne NE2 4AX, UK
    Email: andy.bryant@ncl.ac.uk
    Theresa A Lawrie MBBCh PhD
    Edmund J Fordham PhD FInstP
    EbMCsquared, a Community Interest Company
    Northgate House, Upper Borough Walls, Bath BA1 1RG, UK
    Scott Mitchell MBChB MRCS
    Emergency Department, Princess Elizabeth Hospital, Guernsey

    To the Editor
    The sole substantive critique in this Letter[1] is the description of Bryant[2] et al. (hereafter “Bryant”) as a “bowl of colourful fruit salad”[1], because of the pre-specified comparison of “ivermectin” vs “no ivermectin”. Trials with (potentially) active comparators were indeed included. Reflection should show that any bias is conservatively against ivermectin. Helpful control interventions would dilute the apparent benefit of ivermectin, relative to inactive comparators exclusively. Efficacy will be understated, not overstated, with respect to controls.
    Unsuspected active agents in ivermectin combination therapies might...

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