Recent eLetters

Displaying 1-10 letters out of 12 published

  1. Response to: Legalising Assisted Dying

    I would like to thank Harriet Copperman for her response to my recent editorial. I would like to respond to some of the points she has raised. Harriet says that: We should have the option of an assisted death. For many, just having that option would be sufficient to cope with their death. But a small percentage of people would want to be able to end to their life when it became intolerable. Suicide is not illegal any more. We should therefore, with all the safeguards proposed in the Faulkner bill, enable those people to bring an end to their distress and suffering.

    However, the safeguards don't work. Supporters of Lord Falconer's Bill also argue that, if there are effective safeguards, we can give the right to die for those who wish to hasten their death while protecting those who do not. This argument was used in relation to the 1967 Abortion Act. Whatever one thinks about abortion, David Steel (who as an MP championed abortion reform in the 1960s) has pointed out that the 1967 Abortion Act was intended to stop back street abortions. There were warnings at the time about a slippery slope. And so it has proved to be: despite various safeguards, we now effectively have abortion on demand.

    We also need to listen to the warnings of people living and working in countries where euthanasia or assisted suicide has been legal for some time. The words of Theo Boer, a Dutch ethicist who supported the legalisation of voluntary euthanasia in the Netherlands are particularly pertinent. He cautions against legalising AS in the UK ( Professor Boer believes that the very existence of a law would progressively turn assisted suicide from a last resort to the norm. Data from both Oregon and Belgium lend support to such a view (Finlay and George 2011; Steck et al. 2013).

    Harriet Copperman also states "it is obvious now that with diminishing financial and professional resources and increased bureaucracy, that the goal of 'perfection' will never be achieved, and in my opinion specialist palliative care will become increasingly side- lined." This will become more likely if we legalise assisted suicide as is evident from cases in Oregon in the USA, were two cancer patients were refused funding for chemotherapy but were told that the State would pay for their AS.

    The bottom line remains that in matters of life and death, you cannot create freedom (to die) for the few without taking away adequate safeguards for the many.


    Finlay, I.G. and George, R. Legal physician-assisted suicide in Oregon and the Netherlands; Evidence concerning the impact on patients in vulnerable groups - another perspective on Oregon's data, Journal of Medical Ethics, 2011;37:171-174.

    Steck, N., Egger, M., Maessen, M., Reisch, T. and Zwahlen, M. Euthansia and assisted suicide in selected European Countries and US States: Systematic literature review, Medical Care, 2013;51(10):938-944.

    Conflict of Interest:

    None declared

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  2. Legalising Assisted Dying

    Dear Editor,

    I began practising palliative care in the community in the mid 1970's and retired nearly 25 years later, having been involved with the care of thousands of dying patients. We were evangelical in our attempts to teach and spread the 'gospel of palliative care' to professionals, students and lay people, in the UK and around the world. We thought it was the answer to enabling people to have a good death.

    It was a large part of the answer, but not all of it. Alison Twycross points out that the need is to provide good end of care life so that people do not want/need an assisted death. I would have agreed with her in the past, but it is obvious now that with diminishing financial and professional resources and increased bureaucracy, that the goal of 'perfection' will never be achieved, and in my opinion specialist palliative care will become increasingly side-lined.

    Alison Twycross feels that good end of life care would be more likely were there, for example, better education about whether or not to administer antibiotics to someone who is terminally ill. That is actually an excellent example of how we have failed, after 50 years or so of trying to educate everyone appropriately, as Dame Cicely Saunders first taught about that topic in the 1960's. Incidentally, she always used to say "the patients are our teachers", and my addition to that was "while we learn they suffer"!

    The provision of palliative care (and pain control is probably easier to deal with than some other symptoms a patient may have) will never be perfect however much we would like it to be.

    We should have the option of an assisted death. For many, just having that option would be sufficient to cope with their death. But a small percentage of people would want to be able to end to their life when it became intolerable. Suicide is not illegal any more. We should therefore, with all the safeguards proposed in the Faulkner bill, enable those people to bring an end to their distress and suffering.

    Perhaps if we could really feel another's suffering, rather than just empathise, we might have changed the law years ago.

    Conflict of Interest:

    None declared

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  3. 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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  4. 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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  5. 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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  6. 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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  7. 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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  8. 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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  9. 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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  10. 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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