\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Letter to the Editor: Virtual Reality for Acute Pain in Outpatient
Hysteroscopy: A Randomised Controlled Trial}



\author[1]{Eushaa Mirza}%
\author[1]{Moghees Hanif}%
\author[1]{Muhammad Khan}%
\author[2]{Shazia Jaleel}%
\affil[1]{Barts and The London School of Medicine and Dentistry}%
\affil[2]{George Eliot Hospital NHS Trust}%


\vspace{-1em}



  
  \date{June 13, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\textbf{}Dear editor, we have read with interest the study by \emph{Deo
et al.}published in \emph{BJOG: An International Journal of Obstetrics
and Gynaecology} \textsuperscript{1}. We have noted that although the
control and VR group were `\emph{comparable'} regarding previous
hysteroscopies, differences in baseline pain expectation scores between
patients with a previous hysteroscopy and those without were not given.
Each patient has an individual pain experience during hysteroscopy, some
may not experience any pain at all, whereas others feel pain during
cervical manipulation, distension of the uterus, during pipelle biopsy
or delayed pain due to the release of prostaglandins\textsuperscript{2}.
Therefore, it could be possible the VR group has patients who do not
experience any pain at all. It would be beneficial to know if there was
any difference in pain expectation scores between those with prior
experience of hysteroscopy and those without. A further study with a
group known to have painful hysteroscopies could be of immense clinical
value, as this group of patients may experience the greatest benefit.

Furthermore, it is mentioned that \emph{`patients were instructed to
self administer analgesics prior to the procedure (either paracetamol or
non steroidal anti-inflammatory drugs)'} . It would be useful to ask the
patients which specific analgesic they took, the dosage and how long
before the procedure they took the medication. As use of analgesia prior
to the procedure could potentially affect the pain perceived and
therefore the pain scores in both groups; potentially being a
confounding factor. Having more information about analgesia used prior
to the procedure could allow clinicians to identify significant
differences between cohorts with regards to analgesia use and signify a
possible correlation to pain scores.

Finally, it is mentioned that one patient in the VR group had a previous
history of claustrophobia and decided to remove the headset when the
procedure started as she felt claustrophobic. Therefore, the patient
would not have experienced VR throughout the procedure, rather only for
a small period of time, potentially effecting the reported pain score
for that patient and the larger results as study populations were only
20 patients per cohort. To avoid this, the patient could have perhaps
not been included in the results.

\textbf{Disclosure of Interests:} No conflicts to declare.

\textbf{Contribution to Authorship:} All authors were involved in the
conception, analysis, drafting of intellectual content and final
approval of this correspondence letter. All authors are also in
agreement to be accountable for all aspects of work in this
correspondence letter.

\textbf{Details of Ethics Approval:} No ethics approval required.

\textbf{Funding} : No funding.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Deo N, Khan KS, Mak J, Allotey J, Gonzalez Carreras FJ, Fusari G, Benn
  J. Virtual Reality for Acute Pain in Outpatient Hysteroscopy: A
  Randomised Controlled Trial. BJOG: An International Journal of
  Obstetrics \& Gynaecology. 2020 Jun 10.
\item
  Ahmad G, Saluja S, O'Flynn H, Sorrentino A, Leach D, Watson A. Pain
  relief for outpatient hysteroscopy. Cochrane Database of Systematic
  Reviews. 2017(10).
\end{enumerate}

\selectlanguage{english}
\FloatBarrier
\end{document}

