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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Emergency care and resuscitation plans David Pitcher, Zoe Fritz, Madeleine Wang, Juliet A Spiller. 356:doi 10.1136/bmj.j876

In response to Alex Ruck Keene (this series of responses 15 March) I am no expert on Article 8 ECHR, and I agree that there is a lot of work to be done, but ReSPECT does not fit the logic of the MCA.

The MCA very clearly places [suitable empowered] welfare attorneys above anyone else, for the making of best-interests decisions. The very concept of 'a form which is intended to guide decision-making during 'clinical emergencies'' implies an acceptance that some form of decision-making is better than 'an appeal to the principle of necessity'. It follows, that if there is a welfare attorney whose authority extends over the treatment being considered, it should be the attorney [and not the senior clinician] who signs the ReSPECT form. I would also point out, that there is only a single space for the contact details of a single 'legal proxy' in the emergency contacts section of the form: there can be several at attorneys, and if appointed with Joint & Several powers, the decision of any one of those [if the others are out of contact] should control best-interests decision-making, so logically there should be space for all attorneys to be listed on the form [with individual contact details].

This ReSPECT form, not only implies (the detailed covering material will be more 'sophisticated' - but it will be the actual form which most clinicians interact with, and 'take legal understanding from') that medical ethics which flow across national boundaries 'somehow rank before national law', but it is under the control of the clinicians in terms of its being 'signed off'. In my opinion, the form needs to bear the signatures of the laymen who are involved, if it is to promote the necessary integration between clinicians and 'family carers'. If the laymen were also signing ReSPECT, it would in my opinion tend to be a more accurate record of discussions (see re 1).

I am not sure if Alex read my more recent response before he submitted his (both are 15 March), suggesting that ADRTs should be stapled to the front of the ReSPECT form (ref 2) - I'm wondering if he can see a legal misunderstanding in that suggestion ?

As I have pointed out, section 4(6) of the MCA is complex, and reading a document signed only by clinicians, is not in my opinion sufficient for a reader (an emergency clinician) to defensibly claim compliance with section 4(9). What might in my opinion be sufficient to defensibly guide (justify following the recommendation on the form) such a clinician, would be if the form included a section along the lines of:

'We the undersigned, have discussed the patient's best-interests, and we all consider that the recommendation(s) on this form are in the patient's best interests, We confirm that to the best of our knowledge, no person who could make an adequately-informed decision about the patient's best interests, disagrees with the recorded decision'.

Then, everyone closely involved - clinicians and family, friends - needs to sign the document.

But clinicians are starting from the 'wrong place' with best-interests decision making. As I have pointed out (ref 3) an individual should start with a bit of self-examination:

'An honest consideration of section 4 of the Act, first requires a person to answer the question 'Am I sufficiently well-informed to properly consider section 4, and thereby to defensibly claim compliance with section 4(9) ?''

That is a very different question, from 'am I the senior clinician present'.

Ref 1

Ref 2

Ref 3

Competing interests: No competing interests

16 March 2017
Michael H stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage Jemma Mytton, Felicity Evison, Peter J Chilton, Richard J Lilford. 356:doi 10.1136/bmj.j372

Dear Sir,

With regard to the report by Mytton and colleagues:

Firstly; there appears to be errors in Tables 3 and 4 with ovarian cancer rates higher in patients who have had hysterectomy with bilateral oophoectomy than in patients who had their ovaries conserved.

Secondly; I agree with the comments by Savvas and colleagues in relation to hormone replacement therapy (HRT) and would like to add in regard to bowel cancer; the protective effect of oestrogen HRT on bowel cancer are well described (2000). So the significant (p<0.001) increase in bowel cancer in the oophorectomised women may not occur if oestrogen HRT is administered.

Mytton J, Evison F, Chilton P, Lilford R. Removal of all ovarian tissue versus conserving ovarian tissue at time
of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage.
BMJ 2017; 356: j372.

Savvas M, Modares M, Ho W-L. Re: Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage. BMJ 2017; 01 March.

Prihartono N, Palmer JR, Louik C, Shapiro S, Rosenberg L, A case-control study of use of postmenopausal supplements in relation to the risk of large bowel cancer. Cancer Epidemiology Biomarkers Prev 2000; 9:443-7.

Competing interests: No competing interests

16 March 2017
Roger McMaster-Fay
University of Sydney
Penrith, NSW 2750, Australia
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Re: All emergency departments must have GP led triage by October Gareth Iacobucci. 356:doi 10.1136/bmj.j1270

The demand is for GP "LED" triage. The demand is not for a GP to carry out triage. Will the GP be on the premises? Will the GP be able and willing to run from cubicle to cubicle? How many miles must a patient travel before "he/she/it" is ADEQUATELY assessed? The answer is " blowing in the wind".

A quick and COMPETENT assessment and treatment might ensure fewer complications, fewer deaths, less mental anguish to patients, relatives, friends.
Yes? No?

Competing interests: No competing interests

16 March 2017
JK Anand
Retired doctor
Free spirir
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Re: Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis Laurence C Baker, Sean Mackey, et al. 356:doi 10.1136/bmj.j760

Rather than being entirely causal, there is likely an association with benzodiazepine use as a marker for those at higher risk of escalating dosage. Part of such a higher risk would likely be because of the anxiety-abating signal of the early peak opioid sensations. These likely operantly condition those suffering from anxiety, either constitutionally or as a result of difficult life circumstances and learned avoidance, to be the relief that they seek. Either an assurance that their physical pain will diminish allowing them to stop focussing or worrying about it or, simply because it is generally anxiety reducing and helps in escaping from the intolerable feelings associated with facing the realities of life.

As we know the actual sustained pain reducing effect when used regulalry is about 30%..... rather than getting high, most people who get into trouble are just trying to get by; and this whether it is more apparently about hopelessness or physical pain which also often becomes the substitute focus. We are in a "lost" time at the end of this indutsrialized age. The fabric which humans are adapted to is torn. This issue is but one more signal.

Competing interests: No competing interests

16 March 2017
Andre C. Piver
Nelson, B.C., Canada
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Re: David Oliver: Why shouldn’t nurses be graduates? David Oliver. 356:doi 10.1136/bmj.j863

David Oliver may be missing the wood for the trees with his comments on why graduate nurses are better. A key problem the UK NHS faces is lack of sufficient UK nursing graduates to staff its many services. The current result is three-fold - NHS nurses have to work harder in a relatively under-staffed environment than they should (which reduces care to patients, and makes nursing a less attractive profession to enter); the NHS must recruit large numbers of new nurses from overseas to fill the gaps (which drains developing countries of nursing skills they sorely need, and exposes patients to care by personnel often less familiar with colloquial English); and many tasks that have traditionally been done by fully-trained nurses are now delegated to employees with less training (which means that patients may no longer view a Registered Nurse as their closest ally in hospital).

For the UK NHS nursing service to become locally sustainable, it must attract more young men and women to study nursing in the UK, and then to stay in the profession within the NHS. A partial way to achieve this may be to open up (again) a parallel path to becoming a Registered Nurse within teaching hospitals, that does not require some years of university-based study. Only when there are comparable cohorts of nurses trained via universities AND via such a pathway could a study be done to see whether different modes of training (in modern times) result in different clinical outcomes and/or satisfaction for patients.

In the meantime, saying that graduate nurses are better - when the UK just cannot train and retain sufficient numbers - seems a bit like telling passengers on The Titanic the lifeboats were well made - when there just weren't enough of them!

Competing interests: No competing interests

16 March 2017
Michael Copeman
Copeman Clinic
PALM BEACH NSW 2108 Australia
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Re: Standards for Reporting Implementation Studies (StaRI) Statement Gonzalo Grandes, Chris J Griffiths, Jo Rycroft-Malone, Paul Meissner, et al. 356:doi 10.1136/bmj.i6795

To the Editor,
We were surprised to see the recently published StaRI guidelines for implementation science [Pinnock et al]. StaRI is strikingly similar to SQUIRE 2.0 – the publication guidelines to promote excellence in healthcare improvement reporting1. We are concerned that StaRI may create unintended confusion in the field.

The SQUIRE guidelines represent the input of hundreds of people over a 10 year period of transparent development, evaluation, and revision2-5. We recognize that the StaRI team may have been unaware of the philosophy and development that SQUIRE represents, just as we were unaware of the work of StaRI until its release. We believe the divisions between the science of improvement and implementation science are a false dichotomy. Thus, we will use this forum to briefly outline where the StaRI and SQUIRE converge. We hope this will facilitate a dialogue that can move the field forward as a whole.

The purpose of StaRI and SQUIRE share the same spirit. SQUIRE “provide[s] a framework for the reporting of new knowledge about how to improve healthcare”. StaRI’s purpose is “improve reporting of implementation studies … with the aim of enhancing adoption and sustainability of effective interventions”.

The scope of StaRI and SQUIRE are the same: both cover ‘the range of designs’ used in the field. Additionally, both guidelines indicate that not all items will apply to every study, and should not be required for every manuscript.

A goal for the most recent version of SQUIRE was to create clarity around terminology – favoring plain language over field-specific jargon. It has three key concepts. Authors who use SQUIRE should provide a rationale for their intervention, should study their intervention(s) - not simply report outcomes, and should describe the context of the work. SQUIRE’s three key concepts are recapitulated in StaRI ‘s two defining concepts and 3 overarching components.

In the first defining concept of StaRI, authors are urged to describe the strategy of implementation. Though the authors do not reference TIDIER, these guidelines were released in 2014 and provide a framework for clear reporting of interventions6. SQUIRE directs authors to this tool for the appropriate guidance.

In the second defining concept, StaRI asks authors to report the “impact of the intervention on the health of the target population … [and] even when the evidence is strong, [consider] the possibility that the intervention may be attenuated…”. The items for this include assessments of fidelity, resource use, costs, etc. This is nearly the same as the SQUIRE key concept that invites authors to ‘study their intervention’. The items for StaRI and SQUIRE in this area are similar.

The first of StaRI’s three overarching components is that there must be a hypothesis. This approximates the first key concept of SQUIRE, that there should be a theory or rationale underpinning the proposed interventions7.

The second component of StaRI is the requirement to describe the balance between fidelity to and adaptation of the intervention. It is highly similar to the TIDIER guidelines and also contains elements that SQUIRE places under the heading of ‘the study of the intervention’. This concept is hard to understand and communicate (whether in SQUIRE or StaRI), but at least one publication addresses it8. When we teach about SQUIRE we use the following plain language to describe this concept: ‘did things get better for the reasons you think they did? Were there unintended consequences? What was the impact of the intervention on the people, processes and systems involved?’

The third component of StaRI is the requirement that authors describe context. SQUIRE incorporates items for the description of context in the methods, results and discussion section.

StaRI describes SQUIRE as a publication guideline for quality improvement reports, but this conflates SQUIRE with the classic eight point guideline for quality improvement reports by Moss and Thompson9. SQUIRE is distinguished from Moss and Thompson’s work by having a different purpose, which is to support the reporting of “formal planned empirical studies on the development and testing of improvement interventions”2 and the “reporting of new knowledge about how to improve health care”1. Moss and Thompson’s quality improvement report guideline offers an alternative to the IMRaD format of biomedical reporting, while SQUIRE stays within the IMRaD format.

During the development of SQUIRE 2.0, we noted that the words ‘quality improvement’ had become confusing, because the phrase is associated with specific methodologies that are used in this area of work. SQUIRE is not intended to be restricted to these, but rather applies to any systematic method to improve the quality, safety, and value of healthcare. To resolve the confusion, we retained the SQUIRE acronym to hold on to the guideline’s origins and history, but explicitly moved toward clearer language – SQUIRE’s tag line is now: “promoting excellence in healthcare improvement reporting”. This accurately reflects the intent of the guidelines by leaving space for the many ways and methods that one might use to improve healthcare.

To be sure, some differences between StaRI and SQUIRE remain, especially in the assumptions about timing of iteration and adaptation of interventions. StaRI emphasizes alterations to a specific planned intervention during execution (“implementation cycle”). In SQUIRE the alterations are assumed to most typically occur during both development and execution. SQUIRE does not constrain alterations to a specific time frame.

As we reflect, we are struck by the fact that one field has named itself for the process of making healthcare better (implementation science) while the other has named itself for the hoped for outcome (the science of healthcare improvement). There are more similarities between our work than differences, and we hope this is the beginning of a discussion that can harmonize our science and decrease confusion.

Louise Davies - For the SQUIRE Leadership Team
Greg Ogrinc
Hilary Mosher
David P. Stevens
Frank Davidoff
Gail Armstrong
Paul Batalden
Daisy Goodman

1. Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ quality & safety. Sep 14 2015.
2. Davidoff F, Batalden PB, Stevens DP, Ogrinc GS, Mooney SE, Group SD. Development of the SQUIRE Publication Guidelines: evolution of the SQUIRE project. BMJ quality & safety. Nov 2008;34(11):681-687.
3. Davies L, Batalden P, Davidoff F, Stevens D, Ogrinc G. The SQUIRE Guidelines: an evaluation from the field, 5 years post release. BMJ quality & safety. Dec 2015;24(12):769-775.
4. Davidoff F, Batalden P. Toward stronger evidence on quality improvement. Draft publication guidelines: the beginning of a consensus project. Qual Saf Health Care. Oct 2005;14(5):319-325.
5. Davies L, Donnelly KZ, Goodman DJ, Ogrinc G. Findings from a novel approach to publication guideline revision: user road testing of a draft version of SQUIRE 2.0. BMJ quality & safety. Apr 2016;25(4):265-272.
6. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.
7. Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in improvement. BMJ quality & safety. Jan 23 2015.
8. Portela MC, Pronovost PJ, Woodcock T, Carter P, Dixon-Woods M. How to study improvement interventions: a brief overview of possible study types. BMJ quality & safety. May 2015;24(5):325-336.
9. Moss F, Thompson R. A new structure for quality improvement reports. Quality in health care : QHC. Jun 1999;8(2):76.

Competing interests: No competing interests

16 March 2017
Louise Davies
surgeon, researcher
Greg Ogrinc, Hilary Mosher, David P.Stevens, Frank Davidoff, Gail Armstrong, Paul Batalden, Daisy Goodman
Department of Veterans Affairs, White River Junction, VT and Geisel School of Medicine at Dartmouth, Hanover, NH, USA
VA Outcomes Group - 111B 215 North Main Street White River Junction, Vermont, 05009 USA
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Re: Creative consultations Richard Hurley. 356:doi 10.1136/bmj.j1310

Creativity cures crisis. So let's be visionaries and missionaries, who value creativity and view crises as painful, but productive, prerequisites and preludes to progress and success. Intimidating but stimulating, and aggravating but animating, our copious social, political, financial, and scientific crises are cris de coeur for creativity and vivid, viable overtures to invention. Innovation deserves a standing ovation.

Competing interests: No competing interests

15 March 2017
Hugh Mann
New York, NY, USA
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Re: My mum’s care means that decisions not to resuscitate must now be discussed with patients Kate Masters. 356:doi 10.1136/bmj.j1084

Santhanam Sundar
Consultant Oncologist
Nottingham University Hospital NHS trust
City Hospital Campus, Nottingham

Thank you for your response. Your view is one I have come to agree with over time. I feel the fact that CPR is the one universally expected, yet never consented treatment could be hampering the discussion of DNACPR. Because we never consent, we are never told the 'benefits and burdens' (to coin the clinical phraseology) and never get to know the low success rate and potential brutality of the treatment. I can't see how a formalised consent process would ever work for a life saving emergency treatment but there must be a place for this discussion at some point in our lives? Then, when it comes to our natural death, maybe it would be easier to understand the limits of CPR. The situation now is that those limits hit us square between the eyes like a big surprise, at a very vulnerable time, and if not communicated well can breed mistrust and a feeling of being denied something that's been a given all our lives.

(As an endnote, I will be at NUH's DNACPR event on 11 May, If you are around please come over and say hi! )

Competing interests: No competing interests

15 March 2017
KAte Masters
Author of the piece
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Re: Sepsis should be treated within one hour, says NICE Jacqui Wise. 356:doi 10.1136/bmj.j1257

Dear Sir,

Early identification of patients with sepsis saves lives. The recently announced UK National Institute for Health and Care Excellence (NICE) quality standards are therefore laudable in principle. The practical reality of applying them to the broader definition of sepsis outlined by the 2016 NICE sepsis guidance[1] is unclear.

That a new definition was needed is in little doubt. There had long been an appreciation that the 2001 Systemic Inflammatory Response Syndrome (SIRS) based definition[2] was inadequate being insufficiently sensitive, or indeed specific. NICE anticipated the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)[3] and removed SIRS from its definition producing a more inclusive version based on broader clinical criteria (e.g. confusion, ashen appearance) with the intention of identifying people who would not previously have been categorized as septic.

Operationalizing these guidelines may therefore result in an abrupt increase in the number of people requiring urgent assessment – many perhaps unnecessarily. This will have implications for NHS hospitals already facing limited staffing, increased patient numbers, and a requirement for good antibiotic stewardship. In addition there may be financial penalties for failing to achieve government targets. A current NHS England “Quality and Innovation” (CQUIN) target mandates administration of antibiotics within 60 minutes for patients labeled “septic”.

To establish the proportion of patients classified as “septic” by NICE guidance compared to previous SIRS-based criteria, we retrospectively reviewed the initial medical clerking of 415 consecutive patients presenting over seven days to the acute medical unit of our urban general hospital. The clinical information necessary for the application of the two sepsis definitions was collected. An infection specialist independently reviewed the records and indicated whether they felt the patient required urgent treatment for sepsis. In the absence of any other, this was used as the gold standard against which to compare the various screening scores (data submitted).

SIRS-based criteria classified 20% (95% CI 16 – 24) as septic whereas NICE-recommended criteria identified 33%, (95% CI 29 – 38). The Sepsis-3 proposed “qSOFA” screening tool defined just 4% as septic.

Compared to a consultant’s clinical impression of sepsis, SIRS-based criteria had a sensitivity of 76% (95% CI 60-87) and specificity of 87% (95% CI 83 – 90). Using NICE sepsis guidelines sensitivity was similar at 84% (95% CI 71-94) but specificity fell to 73% (95% CI 47-60). qSOFA scoring had the lowest sensitivity at 13% (95% CI 5 – 27) but highest specificity at 95% (95% CI 95 – 99).

22 people were admitted to ITU or died within 14 days. Of these 9 were identified by both SIRS-based and NICE sepsis definitions. No additional patients were recognised by SIRS-based criteria alone but NICE guidance identified 7 additional patients. qSOFA identified 7 patients from the death/ITU group all of which were identified by NICE and 5 by SIRS-based definitions.

We concluded that implementing NICE sepsis guidance will have an operational impact with one third of acute medical take being classed as requiring urgent antibiotic administration. It is not clear to what extent this is clinically justified - improved sensitivity has come at the cost of significantly reduced specificity.

Given the staffing pressures and limited extent of immediate senior medical availability, particularly overnight, it is likely that this will lead to an increase in the administration of unnecessary – or at least unnecessarily broad-spectrum – antibiotics with implications for stewardship, complications and the risk of later bacterial resistance. We are aware that junior doctors – those making the point of care decisions – tend to associate the label of “sepsis” with the need for broader-spectrum antibiotics, often inappropriately. In our cohort 54% of patients labeled as septic by NICE had some form of chest infection and would have been well managed via standard chest infection management pathways. In addition the quality standards, combined with well-intentioned government CQUIN target for sepsis, may have unintended consequences: it has become apparent that patients are being given antibiotics hours before they are formally assessed. In part this may be the face of good medicine in the context of pressurized system – but hospitals need to be cautious that it does not become primarily a means to avoid a financial penalty. Contemporary meta-analyses of studies of antibiotic timing are not universal in their support for the one hour target[4] – the benefit is more likely to be detectable in cohorts of particularly high mortality. Early antibiotics are after all just one component of the management of those with infections and whilst a CQUIN for antibiotic administration is easy to measure there are many other unmeasured aspects of care that may be more important.

Sepsis-3 very deliberately did away with the concept of severe sepsis, implying that all sepsis was by definition, life-threatening. However a tool that classifies 33% of medical admissions as septic needs further refining, perhaps even a return to risk stratification by incorporating a score such as qSOFA. Whilst not sensitive enough to be used alone, qSOFA does appear to be very effective at recognizing those patients likely to experience an adverse outcome[5] and therefore most likely to benefit from urgent senior medical attention.

In conclusion, hospitals need to implement NICE guidance cautiously and in parallel with robust antibiotic stewardship systems. NICE recommendations need to be subject to ongoing prospective research with the aim of clarifying their sensitivity and specificity and identifying how they can be improved.

Yours sincerely,

Melinda Munang
Cathleen Chan
Saleem Chaudhri
Methini Himayakanthan
Steven Laird
Amy Moltu
Natasha Naworynsky
Christopher Pollard
Tahir Saeed
Paul Scott
Maya Sussman
Shaun Thein
George Trafford
Ariyur Balaji
Neil Jenkins
Ed Moran

Dept of Infection and Dept of Acute Medicine,
Heart of England NHS Foundation Trust, Birmingham.

1 Suspected sepsis: summary of NICE guidance. 2016;354:i4030.
2 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. 2003. 1250–6. doi:10.1097/01.CCM.0000050454.01978.3B
3 The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2016. 801–10. doi:10.1001/jama.2016.0287
4 Sterling SA, Miller WR, Pryor J, et al. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Crit Care Med 2015;43:1907–15. doi:10.1097/CCM.0000000000001142
5 Donnelly JP, Safford MM, Shapiro NI, et al. Application of the Third International Consensus Definitions for Sepsis (Sepsis-3) Classification: a retrospective population-based cohort study. Lancet Infect Dis 2017;0. doi:10.1016/S1473-3099(17)30117-2

Competing interests: No competing interests

15 March 2017
Ed Moran
Consultant in Infectious Disease
Melinda Munang, Cathleen Chan, Saleem Chaudhri, Methini Himayakanthan, Steven Laird, Amy Moltu, Natasha Naworynsky, Christopher Pollard, Tahir Saeed, Paul Scott, Maya Sussman, Shaun Thein, George Trafford, Ariyur Balaji, Neil Jenkins
Heart of England NHS FT
Dept of Infection, Heartlands Hospital, Bordesley Green E, Birmingham.
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Re: Paediatric hearing loss Hannah Nieto, James Dearden, Stacey Dale, Jayesh Doshi. 356:doi 10.1136/bmj.j803

Dear Authors, many thanks for this pertinent resource, which will also be of benefit to ENT trainees. Nevertheless, we would be grateful for clarification of one question: in view of the fact that you advocate age-appropriate hearing tests and tympanometry for all patients falling within your stipulated guidelines, what additional benefit will be gained from also performing the suggested tuning fork tests?

We are not aware of non-specialist settings that have age-appropriate hearing tests and tympanometry immediately available – in these instances, tuning fork tests will be most appropriate and will give an indication as to the type of hearing loss in question. In these settings, should tuning forks not be available, we recommend use of the previously described “hum test” (Rauch, 2008). A subsequent referral for age-appropriate hearing tests and tympanometry can then be made, but is likely to also require input from either Audiovestibular Medicine or ENT. In contrast, in settings that have easy and immediate access to age-appropriate hearing tests and tympanometry, these should be utilised, rendering tuning fork tests almost superfluous.

Rauch, S D (2008). Idiopathic Sudden Sensorineural Hearing Loss. New England Journal of Medicine, 359(8): 833-840

Competing interests: No competing interests

15 March 2017
Thomas Hampton
Lucy Dalton (ST7 ENT, Wirral University Teaching Hospital NHS Foundation Trust)
Wirral University Teaching Hospital NHS Foundation Trust
Arrowe Park Road, Upton, Merseyside, CH49 5PE
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