Recent eLetters

Displaying 1-10 letters out of 10 published

  1. Nurses can help improve secondary cardiovascular prevention

    Koelewijn-van Loon commented on our study, a pragmatic randomised trial of the clinical effectiveness of nurses as substitutes for GPs in cardiovascular risk management. In our study, we found a greater decrease in the mean value of risk factors in the practice nurse group than in the GP group, but after confounders and baseline risk factors were controlled for, a statistically significant decrease was found only for total cholesterol [1].

    The majority of patients included concerned secondary prevention. Indeed, "these patients were probably already aware of the need for a good lifestyle". Still, we found that many patients did not meet the treatment targets and were not adherent to a healthy lifestyle. Non-adherence to treatment is a major factor in the lack of success of cardiovascular prevention hence caregivers should communicate with patients about their drug use and adherence to life style interventions. In this regard, improvement of cardiovascular prevention is still needed. The outcomes achieved by practice nurses were better than those of general practitioners, still nurses only inquired about drug use in only 40% of patients [2].

    Koelewijn-van Loon did question if the effect is caused by nurses acting as substitutes for GPs or by the fact that "nurses were specifically trained", "nurses performed well because this new task recognized their position" or/and "nurses were familiar with lifestyle counselling in contrast to GPs". Indeed, these factors could give an explanation for the results achieved by practice nurses, still cardiovascular risk management was a new task for practice nurses in our study. In addition, they were not specifically trained. Therefore, it is expected that in the future practice nurses will achieve even better health outcomes, as their education improves and more experience is gained. The possibility must be taken into account that practice nurses in our study were more successful compared to other practice nurses because of the awareness that their performance was being assessed. However, this also could be stated for participating general practitioners. Our qualitative study among nurses also showed that nurses in our study were uncertain about the content of lifestyle advice [3]. Still, we found that practice nurses play an important role in the successive removal of barriers to the implementation of cardiovascular prevention within the health care centre and therefore will improve cardiovascular prevention in primary care. It could be concluded that substitution of cardiovascular risk management from GPs to practice nurses concerns more the performance of complementary tasks instead of substitution of tasks.

    Another comment concerned the study population being unbalanced. From an univariate analysis of variance - with control for healthcare centre - no baseline differences were found, except for body mass index (SBP:1.9(-1.4-5.3)p=0.258, DBP:0.003(-1.70-0.17)p=0.997, TChol:-0.07(-0.03 -0.12)p=0.460, LDL:-0.03(-0.22-0.16)p=0.783, HDL:0.06(-.001-0.123)p=0.055, BMI-1.05(-1.76--0.34)p=0.004). Body mass index was underestimated in the general practitioner group because of the lack of correction for self-reported body length.

    Our conclusion that practice nurses achieve the same or even better results in cardiovascular risk management compared with GPs is therefore justified. However, more education for nurses is needed; this training should include knowledge of cardiovascular diseases (symptoms) to allow early recognition of recurrences or new expressions of cardiovascular disease, cardiovascular pharmacology and content of lifestyle intervention related to cardiovascular diseases. Moreover, it is important to enhance practical skills in lifestyle interventions.

    REFERENCES 1. Voogdt-Pruis HR, Beusmans GH, Gorgels AP, Kester AD, Van Ree JW. Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial. Br J Gen Pract.2010 Jan;60(570):40-6.

    2. Voogdt-Pruis HR, Van Ree JW, Gorgels AP, Beusmans GH. Adherence to a guideline on cardiovascular prevention: A comparison between general practitioners and practice nurses. Int J Nurs Stud. 2010 Dec 20. doi:10.1016/j.ijnurstu.2010.11.008.

    3.Voogdt-Pruis HR, Beusmans GHMI, Gorgels APM, Van Ree JW. Experiences of doctors and nurses implementing nurse-delivered cardiovascular prevention in primary care: a qualitative study. Journal of Advanced Nursing. 2011; doi: 10.1111/j.1365-2648.2011.05627.

    Conflict of Interest:

    None declared

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  2. Seclusion: treatment or punishment?

    Dear Editor,

    As a Mental Health Nurse of some 30 years practice I wish to compliment Helen Kirkpatrick on her insightful article regarding the primarily counter-therapeutic effects seclusion has in the overall treatment of the mentally ill person.

    As an RN working in a state run facility I can personally attest to a horrible treatment plan that was referred to as "Voluntary Open Quiet Room". During the course of this treatment some of my patients were made to stay in a seclusion room 'voluntarily' for up to a year at a time. If the patient came out of the voluntary quiet room I and the other nurses were told to call the doctor to obtain an order for either 4-points or locked door seclusion.

    My patients felt coerced and did not like this treatment plan. After pleading with the administration on behalf of my patients to stop this "illegal" treatment plan I had little choice but to empower my patients. I contacted legal aid and was able to obtain a mental health lawyer who my patients were able to personally communicate with on their own behalf.

    Based on the patients complaints the lawyer in part made the following summation to convince the Department of Mental Health to stop this treatment plan:

    1. Isolation inhibited the patients' access to treatment and may even worsen their mental health.

    2. The need to keep a patient safe should not require the patient to forfeit fundamental aspect of care, including regular treatment, contact with patients and staff and dignity. In fact, such forfeitures themselves might make a patient to self-injure.

    And so perhaps patients are right even legally in viewing that this and similar plans as described in Ms Kirkpatrick article is not only undesirable to patients but may prove to be a criminal act of punishment against their person as well.

    Warm regards,
    Thomas M Fraser RN

    No competing financial interest declared.

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  3. Catching up with the times

    Dear Editor,

    I was so glad when my daughter, also a nurse, found this piece of research. I note with sadness the date - 2001.

    I live in the wilds of Essex, at least 25 miles from the great 'metropolis'. Two years ago I had a vile stroke, so I no longer drive. Recently 'they' noticed that I had AF and must start on anticoagulant treatment instantly. There is a proudly "Nurse led Clinic" at a hospital some half an hour away. It works well BUT the transport picks up patients from all over Essex. Not only is one frequently collected two or three hours before the clinic, but one has to wait for transport for several hours AFTER the efficient 3 minute blood test.

    The logistics of this are understandable, but I did begin to wonder why I couldn't do the test myself, or at least go to the much nearer surgery. I kept being told that one had to be 'specially trained'- or that the blood test that was done in the ward was 'different' and needed venous blood - a constant denial of the facts - nurses and doctors kept insisting on their exclusive magical powers.

    First we bought the kit - annoyingly expensive! The GP won't play ball, though I keep meeting people who know of practices which are happy to. Nor will the hospital clinic accept my readings - so far. I find the Clinic visits exhausting and 'bad for my health', and I am by no means among the most decrepit of some of the poor folk I travel with, and who sit in wheel chairs waiting for transport.

    As a professional who often pioneered small changes in Family Practice which made things easier for our patients I am irritated by this failure to take up simple changes in practice which benefit all of us.

    Julia Wyatt
    SRN BA Hons (Lond)

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  4. Author's Reply

    Dear Editor

    Dr Parienti and colleagues have raised concerns [1] about a section of the commentary for which I am responsible. Their letter highlights the lack of a standard typology for trial design in clinical epidemiology. At the heart of this issue is not only what to call the different types of clinical trial, but how to analyse the results of each trial. Was the trial by Dr Parienti and colleagues a cluster randomised controlled trial (RCT) as I described it? In the trial each service (or study centre) was randomised to an alternating sequence, commencing with either the alcohol handrub first, or handscrubbing first. The trial could have been described as a cross-over design, although in cross-over designs, it is usually an individual that is randomised to an order of treatment.[2] Where the unit of randomisation is an intact social unit, such as a community, family, or service, the trial is usually called a cluster RCT.[3] Dr Parienti quite rightly points out that in cluster RCTs the study centre is normally randomised to the treatment or control, whereas he and his colleagues randomised each service to a sequence of interventions. Therefore, perhaps the trial is most accurately described as a cluster cross-over RCT.

    The substantive issue in Dr Parienti's letter is how their trial should have been analysed. It is my view that the trial should have been analysed as though it were a cluster design, as services were randomised to a sequence of interventions. Cluster designs can balance out the impact of extraneous variables, but less efficiently than trials that randomise by individual. Cluster designs normally adjust for this by inflating the number of clusters and participants that need to be enrolled in the trial.[4] Dr Parienti and colleagues do not seem to have done this, and there were only six services (or clusters) in their study. As Dr Parienti states, each service would have acted as its own control, and the 15 sequential cross-over periods certainly adds to the study's validity. I was perhaps remiss in not pointing this out in the commentary.

    Even though the cross-over periods controlled for between-cluster variance, the investigators did not analyse for the impact of time periods. Each service has a flow of patients and staff through it that will vary in some way - for instance there will be seasonal variation, which even if small, could influence the outcome. Therefore the services will not be the same over time. If the patients or the cross-over periods had been randomised, then the possible influence of this effect would have been balanced out. Randomising the service to an sequence of intervention would not have been able to control for this effect; and thus the trial's standard error could actually be greater, confidence intervals wider, and the p values larger than the reported result.[5] If a multi-level analysis (patient, time period and service) had been conducted then the reader could be reasonably assured of the lack of difference between the interventions. It is possible that even had Dr Parienti and colleagues used this method of analysis, they would have found little difference from the result they published. However, Dr Parienti and colleagues did not follow the dictum "as you randomise, so you shall analyse" and the knowledgeable reader is left uncertain as to whether handrubbing with alcohol as compared with handscrubbing is as equivalent as the study reports.

    I am grateful to Dr David Torgerson, University of York, and Mark Jones, University of Auckland, for their helpful review.


    (1) Jean-Jacques Parienti, for the ACM study group. Only cluster design lead to cluster effect [electronic response to Moralejo D and Jull D Handrubbing with an aqueous alcohol solution was as effective as handscrubbing with antiseptic soap for preventing surgical site infections] 2003

    (2) Jadad AR. Randomised controlled trials. London: BMJ Books,1998.

    (3) Donner A, Klar N. Design and analysis of cluster randomization trials in health research. London: Arnold, 2000.

    (4) Kerry SM, Bland JM. Analysis of trials randomised in clusters. BMJ 1998;316:54.

    (5) Bland JM, Kerry SM. Trials randomised in clusters. BMJ 1997;315:600.

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  5. Only cluster design lead to cluster effect

    Dear Editor

    On behalf our Study group, I would like to thank EBN’s Editors for their interest in our work.

    In their review, major concerns regarding the design and analysis of our study were raised by Drs Moralejo and Jull, mainly because antiseptic protocols were randomised by services (called "clusters") but outcome was analysed by patients. The authors concluded that while our trial is intriguing, "whether hand rubs and handwashing are truly equivalent remains unclear". In my opinion, the fact that Drs Moralejo and Jull misunderstood the design of our trial does not justify that they unvalidate our conclusion.

    The reason why we did not account for cluster randomisation is simple: the design of our study was not a "cluster randomised trial", as they incorrectly suggested. To be the case, each of the 6 services should have been randomly assigned to one of the 2 protocols for the complete 16-month period of the study. In this case only, characteristics of each service, such as teaching versus non-teaching hospitals or surgical team experience, would have differentially affected outcome, because of intracluster dependence between patients within each service.

    In fact, each service alternated protocols monthly, so that they equally contributed to include patients in both protocols, as shown in Table 1 of our article. Initial randomisation of the services rather than continuous randomisation of patients was not an error but a choice. Its rational was clearly discussed in our article.

    Finally, we must stand on our conclusion that handrubbing and handscrubbing were equivalent in preventing surgical site infection.

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  6. We would like to thank Carlos Kusano Bucalen Ferrari for taking the time to respond to the Commentary by Violeta Ribeiro (EBN 2002; 5:57). Mr Ferrari gives us an interesting overview of the biochemical effects of several antioxidants in laboratory studies. These kinds of studies are frequently the starting point for developing new drugs and treatments but it is important to emphasise that the results of in vitro studies in laboratories are frequently not replicated when a treatment is trialed in the people the drugs are intended for. Therapies which appear to make sense from a physiological or biochemical perspective are often ineffective or harmful when tried in humans. We would therefore very much agree with the sentiments in the last line of the letter - more studies, and particularly clinical trials, are necessary to provide evidence for the clinical benefit of these therapies.

    Professor Nicky Cullum
    Centre for Evidence Based Nursing
    Department of Health Sciences
    University of York
    Alcuin Teaching Building

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  7. Dear Editor

    It is well documented that Free radicals (FRs) and their Oxidative Reactions are implicated in more than 70 diseases and disorders [1,2], including inflammatory reactions, such as alergies and rheumatoid arthritis. As FRs and Oxidative stress are also implicated in many cell death processes [3], many scientific activities are being done to discover possible protective effects of the antioxidant therapy [1]. Today, based on Oriental and Mediterranean dietetic studies, we know that many foods,the functionals or nutraceuticals, can improve physiological properties of the human body, improving health and preventing diseases. I should be emphazised that antioxidant activity of foods is one of the most important functional food atributtes.

    Persenone A, an avocado compound, was able to inhibit two peroxidative enzymes involved in inflammatory responses, the nitric oxide synthase and cyclooxygenase in mouse macrophages [4]. Murcia et al. [5] demonstrated that avocado possess antioxidant activities as well as many other Mediterranean and Tropical Fruits do. Some years ago, Kikusaki and Nakatani [6] had observed that 12 Ginger compounds have antioxidant activity.

    This year, Kim et al. [7] reported that ginger, avocado, carrot, turnip and shimeji mushrooms had higher superoxide radical scavenging activity, suggesting that this phytochemicals can prevent oxidative DNA damage, the first step in cancer carcinogenesis.

    It should be noted that in rheumatoid arthritis, there are intensive production of FRs and the antioxidant therapy is very important to control the damaging effects of these substances. As exposed before, Ginger, Avocado and other foods are rich sources of antioxidants with a great potential to be explored in rheumatoid arthritis. However, many more basic and studies are necessary to support a teraphy.


    (1) Ferrari CKB (1998). Lipid peroxidation in foods and biological systems: General mechanisms and Nutritional and Pathological implications. Rev. Nutr., 11: 3-14 (in portuguese).

    (2) Ferrari CKB (2001). Oxidative Stress Pathophysiology: Searching for an Effective Antioxidant Protection. Int. Med. J., 8: 175-84.

    (3) Ferrari CKB (2000). Free Radicals, lipid peroxidation and antioxidants: Implications for cancer, cardiovascular, and neurological diseases. Biologia, 55: 581-90.

    (4) Kim OK, Murakami A, Takahashi D, Nakamura Y,Torikai K, Kim HW, Ohigashi H (2000). An avocado constituent, persenone A, suppresses expression of inducible forms of nitric oxide synthase and cyclooxygenase in macrophages, and hydrogen peroxide generation in mouse skin. Biosci. Biotechnol. Biochem., 64: 2504-7.

    (5) Murcia MA, Jimenez AM, Martinez-Tomé M (2001). Evaluation of the antioxidant properties of Mediterranean and tropical fruits compared with common food additives. J. Food Protect., 64: 2037-46. (6) Kikusaki H, Nakatani N (1993). Antioxidant effect of some Ginger constituents. J. Food Sci., 58: 1407-10. (7) Kim HW, Murakami A, Nakamura Y, Ohigashi H (2002). Screening of edible Japanese plants for suppressive effects on phorbol ester-induced superoxide generation in differentiated HL-60 cells and AS52 cells. Canc. Let., 176:7-16.

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  8. The significance of needle gauge

    Dear Editors

    Consideration has not been given to the significance of the larger bore needle (23 gauge) affecting the outcome, seperate to the length of the needle. Surely, to exclude this variable by comparing 25mm x 23 gauge, 25mm x 25 gauge, and 16mm x 25 gauge would possibly clarify the significance of the larger bore needle rather than assume the longer length needle as being the sole variant?

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  9. Editors' Reply to eLetter from JC Platt

    Dear Mr Platt

    Many thanks for your eLetter regarding an abstract appearing in both EBM[1] and EBN[2] with different commentaries. In answer to your queries:
    First, when we have the same abstract appearing in both journals we do sometimes use the same commentary as well, however, if we think it doesn't fit our target audience we can require a fresh commentary. The risk is that, like all opinion, differences in interpretation will occur, hiding such differences would not be our preference. The reason why we provide the details that we do in the abstract is so the reader can judge for themselves - this is not only a matter of methods of the study, but also local context. Part of the context here is professional perspective. We did have considerable discussion over this particular article because some details such as the precise interventions were not well described in the paper, though Dr Robertson was helpful in supplying these.

    Having said this, there isn't much difference in the commentaries, if you look at both of them in toto. They don't in fact disagree. John Robbins isn't saying that nurses can't play an important role in a home-based program for preventing falls, and Nancy Edwards isn't saying that this study is definitive for showing that nurses can only do it, or that the effect will be sustained if they do do it. That the two commentators are taking a somewhat different slant on their interpretations of the application of the results is valid, based on their perspectives.

    Second, regarding your suggestion on joint commentaries; having multidisciplinary perspectives presented for each articles would be interesting and potentially informative. But, unfortunately we have to take into consideration obstacles such as the increase in editorial time it would take to prepare a multidisciplinary commentary and the amount of space such text would require. We would need more space for such discourse and would then have less space for other research. The research reports are the "stars" of the publication, so this could be a poor trade-off.

    Finally thank you for suggesting this discourse be mounted on the eLetters page, we are keen to get more discussion going on both the websites but we do rely somewhat on our readers prompting appropriate topics.

    I hope this answers all your queries.

    Yours Sincerely

    The Editors


    (1) Robbins JA, Robertson MC, Campbell AJ (commentator). A home-based, nurse-delivered exercise programme reduced falls and serious injuries in people ³ 80 years of age. Evid Based Med 2001;6:182.

    (2) Edwards N. A home based, nurse delivered exercise programme reduced falls and serious injuries in people 80 years of age. Evid Based Nurs 2002;5:22.

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  10. Response to: A home-based, nurse-delivered exercise programme

    Dear Editors

    The study:
    A home-based, nurse-delivered exercise programme reduced falls and serious injuries in people ³ 80 years of age. Robertson et al. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: randomised controlled trial. [1]
    appeared in both Evidence-Based Medicine [2] and in Evidence-Based Nursing.[3]

    The commentators differ in their perceptions of this paper. Edwards states that "Study results are promising and suggest that nurses have an important role to play in the promotion of appropriate exercise that targets fall prevention among seniors."
    Whereas Robbins believes "We can be less sure from this study what the actual "treatment" needs to be and who should provide it."

    For me several issues are raised:
    ·Is it necessary to replicate summaries of studies in both journals, it seems wasteful of resources
    ·What about the possibility of joint (multidisciplinary) commentaries
    ·The eLetters section where issues such as those I have raised could be aired still contains no letters

    John Platt


    (1) A home-based, nurse-delivered exercise programme reduced falls and serious injuries in people ³ 80 years of age Robertson MC, Devlin N, Gardner MM, et al. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: randomised controlled trial.BMJ 2001 Mar 24;322:697-701.

    (2) Robbins JA, Robertson MC, Campbell AJ (commentator). A home-based, nurse-delivered exercise programme reduced falls and serious injuries in people ³ 80 years of age. Evid Based Med 2001;6:182.

    (3) Edwards N. A home based, nurse delivered exercise programme reduced falls and serious injuries in people 80 years of age. Evid Based Nurs 2002;5:22.

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