My research has detected curious patterns of on/off switching in international deaths. Basically, deaths run at a baseline level and then suddenly switch-on to a new and higher level for around 12 to 18 months after which they switch-off and revert back to the baseline. They stay at baseline until the next switch-on event. Deaths in person's with Alzheimer's and other dementias seem highly sensitive to the switch-on events. This curious behaviour is most readily revealed using a rolling (running or moving) 12-month total or average.
In England, in-hospital deaths show the same on/off-switching.
Should you have access to monthly data it may be useful if you could apply such a rolling 12-month analysis of the data.
Decline in neonatal mortality in Northern Ghana: Non-specific effects of BCG vaccination or Improvements in health systems?
In an ecological study carried out in Northern Ghana, Welaga et al., assessed changes in neonatal mortality rates (NMR) and BCG vaccination age from 2002 to 2012. The authors found that among home deliveries, median BCG vaccination age declined from 46 days in 1996 to 4 days in 2012. Within the same period , NMR decreased from 46 to 12 per 1000 live births (1). The authors concluded their study by suggesting that the significant decline in mortality observed may be due to the beneficial non-specific effects of early BCG vaccination. The authors should be commended for studying whether BCG vaccination may have non-specific effects. However, several issues need to be raised when interpreting these results.
1) Adjustment for other vaccine effects
The authors did not expand on the potential role that improvements on the Expanded Programme on Immunization (EPI) in Ghana may have played in reducing neonatal mortality. Diarrhea and Pneumonia are the main causes of neonatal mortality. Although still sub-optimal, Rotac and PCV3 immunization coverage estimates for Ghana in 2012 were significantly better than in 1996 or 2002 (2). A similar trend was observed for almost all the vaccines in the EPI schedule. For example, UNICEF immunization coverage estimates for Ghana indicate that DTP3 vaccine coverage increased from 71 % in 1996 to 92 %...
Decline in neonatal mortality in Northern Ghana: Non-specific effects of BCG vaccination or Improvements in health systems?
In an ecological study carried out in Northern Ghana, Welaga et al., assessed changes in neonatal mortality rates (NMR) and BCG vaccination age from 2002 to 2012. The authors found that among home deliveries, median BCG vaccination age declined from 46 days in 1996 to 4 days in 2012. Within the same period , NMR decreased from 46 to 12 per 1000 live births (1). The authors concluded their study by suggesting that the significant decline in mortality observed may be due to the beneficial non-specific effects of early BCG vaccination. The authors should be commended for studying whether BCG vaccination may have non-specific effects. However, several issues need to be raised when interpreting these results.
1) Adjustment for other vaccine effects
The authors did not expand on the potential role that improvements on the Expanded Programme on Immunization (EPI) in Ghana may have played in reducing neonatal mortality. Diarrhea and Pneumonia are the main causes of neonatal mortality. Although still sub-optimal, Rotac and PCV3 immunization coverage estimates for Ghana in 2012 were significantly better than in 1996 or 2002 (2). A similar trend was observed for almost all the vaccines in the EPI schedule. For example, UNICEF immunization coverage estimates for Ghana indicate that DTP3 vaccine coverage increased from 71 % in 1996 to 92 % in 2012 (2). These improved vaccination rates may therefore explain why the authors observed such a significant drop in mortality. Although the authors adjusted for year of vaccination, they did not provide any additional information on other vaccines nor did they provide information on which infections were associated with mortality in their study.
2) Heterogeneous effects on BCG and misclassification bias in the study
At the individual level, While BCG vaccination was protective against mortality among girls, the authors found no protective effect associated with BCG among boys ( HR=0.95 (0.20-4.25) (1). This was a surprising effect since BCG is known to reduce the risk of tuberculosis disease by about 50% (3). This suggests that either there was a misclassification of exposure in this study or there were other potential unmeasured confounders affecting these estimates. In addition, it is unclear why the authors did not provide a relative risk estimate comparing mortality among infants that were vaccinated early and those who were vaccinated a few weeks after birth. It seems unlikely that at the individual level, this estimate would be statistically or clinically significant.
3) The role of the neonatal immune system and delayed BCG-vaccination
Neonates’ innate and adaptive immune responses have been shown to improve over time and multiple BCG studies carried out in South African HIV-exposed and HIV-unexposed infants have shown that delaying BCG vaccination to a few weeks after birth leads to improved Th1 responses to BCG antigens but also other antigens such as Tetanus Toxoid(4,5,6). BGG has been shown to induce heterologous protection against unrelated pathogens via epigenetic reprogramming of monocytes (7). However, it is unclear, whether these non-specific effects are affected by the timing of vaccination as the authors seem to suggest in their conclusion (1)
Welaga et al. showed encouraging data indicating that neonatal mortality is significantly decreasing in Northern Ghana. The decline in the median BCG age suggests an overall improvement in health systems in and EPI coverage in Northern Ghana over the years. However, due to the nature of this study, it is difficult to assess the role of early BCG vaccination on neonatal mortality. This study highlights the need for Randomized controlled trials (RCTs) assessing the non-specific beneficial effects of BCG vaccination.
References
1) Welaga P, Debpuur C, Aaby P, Hodgson A, Azongo DK, Benn CS, Oduro AR. Is the decline in neonatal mortality in northern Ghana, 1996–2012, associated with the decline in the age of BCG vaccination? An ecological study. BMJ Open. 2018 Dec 1;8(12):e023752.
2) Ghana: WHO and UNICEF estimates of immunization coverage: 2017 revision accessed at: https://www.who.int/immunization/monitoring_surveillance/data/gha.pdf on December 20th 2018
3) Colditz GA, Brewer TF, Berkey CS, Wilson ME, Burdick E, Fineberg HV, Mosteller F. Efficacy of BCG vaccine in the prevention of tuberculosis: meta-analysis of the published literature. Jama. 1994 Mar 2;271(9):698-702.
4) Kagina BM, Abel B, Bowmaker M, Scriba TJ, Gelderbloem S, Smit E, Erasmus M, Nene N, Walzl G, Black G, Hussey GD. Delaying BCG vaccination from birth to 10 weeks of age may result in an enhanced memory CD4 T cell response. Vaccine. 2009 Sep 4;27(40):5488-95.
5) Tchakoute CT, Hesseling AC, Kidzeru EB, Gamieldien H, Passmore JA, Jones CE, Gray CM, Sodora DL, Jaspan HB. Delaying BCG vaccination until 8 weeks of age results in robust BCG-specific T-cell responses in HIV-exposed infants. The Journal of infectious diseases. 2014 Aug 8;211(3):338-46.
6) Blakney AK, Tchakoute CT, Hesseling AC, Kidzeru EB, Jones CE, Passmore JA, Sodora DL, Gray CM, Jaspan HB. Delayed BCG vaccination results in minimal alterations in T cell immunogenicity of acellular pertussis and tetanus immunizations in HIV-exposed infants. Vaccine. 2015 Sep 11;33(38):4782-9.
7) Kleinnijenhuis J, Quintin J, Preijers F, Joosten LA, Ifrim DC, Saeed S, Jacobs C, van Loenhout J, de Jong D, Stunnenberg HG, Xavier RJ. Bacille Calmette-Guerin induces NOD2-dependent nonspecific protection from reinfection via epigenetic reprogramming of monocytes. Proceedings of the National Academy of Sciences. 2012 Oct 23;109(43):17537-42.
During the peer review process of this manuscript, it came to our attention that one of the reviewers, Erling Solheim, may have an undeclared conflict of interest. We were told that he had worked in the same research group as the authors from June 2006 to September 2007 and had published research with one of the authors in 2008.
We attempted to contact Erling Solheim a number of times to verify these claims, but he did not respond to our emails at the time. We would like to point out, however, that we do not feel that this undeclared conflict of interest (and one from ten years ago) would have compromised the peer review process or altered our decision to publish the manuscript.
There is much evidence that exposure to various chemicals, such as lead, chromium, tin, mercury, welding fumes, silicon and in particular organic solvents, may cause both brain damage1-3 and chronic kidney disease,4-7 including diabetic kidney disease.8 Therefore, I suggest that the authors, assisted by occupational hygienists, investigate whether their patients are exposed to such chemicals.
References
1. Edling C, Ekberg K, Ahlborg G Jr et al. Long-term follow up of workers exposed to solvents. Br J Ind Med 1990;47:75-82.
2. Kukull WA, Larson EB, Bowen JD et al. Solvent exposure as a risk factor for Alzheimer's disease: a case-control study. Am J Epidemiol. 1995;141:1059-71.
3. Yamanouchi N, Okada S, Kodama K, Sato T. Central nervous system impairment caused by chronic solvent abuse-a review of Japanese studies on the clinical and neuroimaging aspects. Addict Biol. 1998;3:15-27. doi: 10.1080/13556219872317.
4. Zimmerman SW, Groehler K, Beirne GJ. Hydrocarbon exposure and chronic glomerulonephritis. Lancet. 1975;2(7927):199–201.
5. Ravnskov U, Lundström S, Nordén Å. Hydrocarbon exposure and glomeru-lonephritis: evidence from patients’ oc¬cupation. Lancet. 1983;2(8361): 1214–6.
6. Nuyts GD, Van Vlem E, Thys J et al. New occupational risk factors for chronic renal failure. Lancet 1995;346(8966):7–11
7. Ravnskov U. Hydrocarbons may worsen renal function in glomerulonephritis: a meta-analysis of the case-control studies. A...
There is much evidence that exposure to various chemicals, such as lead, chromium, tin, mercury, welding fumes, silicon and in particular organic solvents, may cause both brain damage1-3 and chronic kidney disease,4-7 including diabetic kidney disease.8 Therefore, I suggest that the authors, assisted by occupational hygienists, investigate whether their patients are exposed to such chemicals.
References
1. Edling C, Ekberg K, Ahlborg G Jr et al. Long-term follow up of workers exposed to solvents. Br J Ind Med 1990;47:75-82.
2. Kukull WA, Larson EB, Bowen JD et al. Solvent exposure as a risk factor for Alzheimer's disease: a case-control study. Am J Epidemiol. 1995;141:1059-71.
3. Yamanouchi N, Okada S, Kodama K, Sato T. Central nervous system impairment caused by chronic solvent abuse-a review of Japanese studies on the clinical and neuroimaging aspects. Addict Biol. 1998;3:15-27. doi: 10.1080/13556219872317.
4. Zimmerman SW, Groehler K, Beirne GJ. Hydrocarbon exposure and chronic glomerulonephritis. Lancet. 1975;2(7927):199–201.
5. Ravnskov U, Lundström S, Nordén Å. Hydrocarbon exposure and glomeru-lonephritis: evidence from patients’ oc¬cupation. Lancet. 1983;2(8361): 1214–6.
6. Nuyts GD, Van Vlem E, Thys J et al. New occupational risk factors for chronic renal failure. Lancet 1995;346(8966):7–11
7. Ravnskov U. Hydrocarbons may worsen renal function in glomerulonephritis: a meta-analysis of the case-control studies. Am J Ind Med. 2000;37:599-606.
8. Yaqoob M, Patrick AW, McClelland P et al. Occupational hydrocarbon exposure and diabetic nephropathy. Diabet Med. 1994;11:789–93.
This paper highlights the reasons behind high stillbirth in India. The authors have underlined the importance of recording stillbirths to know the reasons why. Now the need is to translate the conclusions of this study into actions. Immediate action is needed to incorporate the reasons highlighted in this study into modules recently published by National Health Mission like, Induction Training Module for ASHAs in Urban Areas and Guidebook for Enhancing Performance of Auxiliary Nurse Midwife (ANM) in Urban Areas, March 2017. Both of these key modules don't focus on stillbirth and its reasons beautifully highlighted in this study. Translating knowledge into action is the first step in controlling the problem in question and this needs to be done at the earliest opportunity to have safe outcome of pregnancy.
1. From this study, the Authors had the aim to examine trends in prevalence of overweight/obesity among adults in India by socioeconomic position (SEP) between 1998 and 2016 but the data that they collected the range was not the same for example they collected the data 1998/1999, 6 years later 2005/2006, then 9 years later 2015/2016. The data from women they collected start from 1998 and for men start from 2005. From this data, maybe many of researchers will ask about this, it is not clear to describe about the prevalence, around 6 or 9 years it had uniqe graphic that we cannot see from this research.
2. BMI is commonly used by the researcher to classify overweight and obesity in adults. Whereas, BMI is not good enough to describe about nutritional status because BMI does not measure about fat, based on World Health Organization (WHO) Expert Consultation in 2002 to review and assess the issues related to whether population-specific BMI cut-off points are needed in Asian populations. Overweight and obesity are not the same, they have different cut-off. As the Authors mentioned for the overweight the cut-off ≥24,99 kg/m2. Maybe we can distinguish between overweight (≥24,99 kg/m2) and obesity (≥30,00 kg/m2) to see the different of prevalence both of them like the research that Sánchez-Cruz (2018) and Muttarak, Raya (2018) were undertaken from their research. So, Policy makers can know how many adults got overweight and obesity, and this result to be more informative a...
1. From this study, the Authors had the aim to examine trends in prevalence of overweight/obesity among adults in India by socioeconomic position (SEP) between 1998 and 2016 but the data that they collected the range was not the same for example they collected the data 1998/1999, 6 years later 2005/2006, then 9 years later 2015/2016. The data from women they collected start from 1998 and for men start from 2005. From this data, maybe many of researchers will ask about this, it is not clear to describe about the prevalence, around 6 or 9 years it had uniqe graphic that we cannot see from this research.
2. BMI is commonly used by the researcher to classify overweight and obesity in adults. Whereas, BMI is not good enough to describe about nutritional status because BMI does not measure about fat, based on World Health Organization (WHO) Expert Consultation in 2002 to review and assess the issues related to whether population-specific BMI cut-off points are needed in Asian populations. Overweight and obesity are not the same, they have different cut-off. As the Authors mentioned for the overweight the cut-off ≥24,99 kg/m2. Maybe we can distinguish between overweight (≥24,99 kg/m2) and obesity (≥30,00 kg/m2) to see the different of prevalence both of them like the research that Sánchez-Cruz (2018) and Muttarak, Raya (2018) were undertaken from their research. So, Policy makers can know how many adults got overweight and obesity, and this result to be more informative and it can make the Policy makers making some evaluation from your research.
References:
1. Sánchez-Cruz, et.al. Stabilization and reversal of child obesity in Andalusia using objective anthropometric measures by socioeconomic status. BMC Pediatrics (2018) 18:322 https://doi.org/10.1186/s12887-018-1295-4
2. Muttarak, Raya. Normalization of Plus Size and the Danger of Unseen Overweight and Obesity in England. Brief Cutting Edge Report EPIDEMIOLOGY/GENETICS (2018) 26, 1125–1129. doi:10.1002/oby.22204
Sintha Dewi Purnamasari sinthadewi14@gmail.com
Master Student of Nutrition and Health Sciences
Taipei Medical University
Comments on Patel et al., Maternal anaemia and underweight as determinants of pregnancy outcomes: cohortstudy in eastern rural Maharashtra, India. BMJ Open. 2018 Aug 8;8(8):e021623. doi: 10.1136/bmjopen-2018-021623
Dear Sir I have read your above article with great interest and I have to congratulate you on this work.
You investigated an important topic “Anaemia” and its maternal and perinatal outcomes.
As you have mentioned that anaemia is common health problem and it can lead to adverse pregnancy outcomes. I think unlike the other maternal and perinatal outcomes, there are few publish data on association between anemia and cesarean section.1,2
You have mentioned that “The risks of CS and pregnancy-related complications during delivery were significantly higher in non-anaemic women versus anaemic women for both data sets (page 4 the first line in Study outcomes: regression.
These points have also been shown in table 2 in which 20.85%, 23.8% and 29.8% of women with moderate/severe, mild anaemia and non-anaemic women, respectively have cesarean section.
Lower down in table 3 A it have been mentioned that women with severe /moderate anaemia and women with mild anaemia have lower risk of cesarean section (OR= 0.89, 95% CI=(0.84 to 0.95) and OR= 0.91, 95% CI=(0.86 to 0.97), respectively.
I think the reverse might result if you combined both types of anemia severe/moderate and mild together (20.85%+ 23.8%= 44.65%). Then your result wo...
Comments on Patel et al., Maternal anaemia and underweight as determinants of pregnancy outcomes: cohortstudy in eastern rural Maharashtra, India. BMJ Open. 2018 Aug 8;8(8):e021623. doi: 10.1136/bmjopen-2018-021623
Dear Sir I have read your above article with great interest and I have to congratulate you on this work.
You investigated an important topic “Anaemia” and its maternal and perinatal outcomes.
As you have mentioned that anaemia is common health problem and it can lead to adverse pregnancy outcomes. I think unlike the other maternal and perinatal outcomes, there are few publish data on association between anemia and cesarean section.1,2
You have mentioned that “The risks of CS and pregnancy-related complications during delivery were significantly higher in non-anaemic women versus anaemic women for both data sets (page 4 the first line in Study outcomes: regression.
These points have also been shown in table 2 in which 20.85%, 23.8% and 29.8% of women with moderate/severe, mild anaemia and non-anaemic women, respectively have cesarean section.
Lower down in table 3 A it have been mentioned that women with severe /moderate anaemia and women with mild anaemia have lower risk of cesarean section (OR= 0.89, 95% CI=(0.84 to 0.95) and OR= 0.91, 95% CI=(0.86 to 0.97), respectively.
I think the reverse might result if you combined both types of anemia severe/moderate and mild together (20.85%+ 23.8%= 44.65%). Then your result would read as anaemia increase the rate of cesarean section in univariate analyses (OR=2.7, 95%CI=2.56–2.84), P<0.001.
Then you can adjust for the other factor. Thereafter your findings will be similar to previous reports on association of anaemia and cesarean section. 1,2
Regards
Prof. Ishag Adam, MD,
Faculty of Medicine, University of Khartoum, PO Box 102, Khartoum, Sudan
Tel +249912168988, Fax +249183771211 ishagadam@hotmail.com
Reference
1.Levy A, Fraser D, Katz M, Mazor M, Sheiner EMaternal anemia during pregnancy is an independent risk factor for low birthweight and preterm delivery. Eur J Obstet Gynecol Reprod Biol. 2005 Oct 1;122(2):182-6.
2.Drukker L, Hants Y, Farkash R, Ruchlemer R, Samueloff A, Grisaru-Granovsky SIron deficiency anemia at admission for labor and delivery is associated with an increased risk for Cesarean section and adverse maternal and neonatal outcomes. Transfusion. 2015 Dec;55(12):2799-806
73. N71.9 - Inflammatory disease of uterus, unspecified
86. K57.1 - Diverticular disease of small intestine without perforation or abscess
90. N48.1 - Balanoposthitis
99. N48.2 - Other inflammatory disorders of penis
130. J69.8 - Pneumonitis due to other solids and liquids
The remaining 258 codes had 45521 cases with 3163 associated deaths.
95% of cases are captured using the first 76 diagnostic codes.
We felt that many of the cases reflected infections that are highly unlikely to progress to death
One would expect this with a condition associated with sepsis.
We ranked the remaining codings by number of deaths.
95% of deaths would be captured in just 24 diagnostic codes.
We added in a number of codes that were highly likely to represent relatively common sepsis conditions,
with mortality over 10% and more than 10 cases.
117. A49.9 - Bacterial infection, unspecified
118. A40.0 - Sepsis due to streptococcus, group A
121. A41.2 - Sepsis due to unspecified staphylococcus
131. A40.3 - Sepsis due to Streptococcus pneumoniae
116. G00.9 - Bacterial meningitis, unspecified
Altogether, these 29 codes accounted for 29424 episodes with 3026 deaths :
Pneumonia
J22.X - Unspecified acute lower respiratory infection
J18.9 - Pneumonia, unspecified
J44.0 - COPD with acute lower respiratory infection
J18.0 - Bronchopneumonia, unspecified
J13.X - Pneumonia due to Streptococcus pneumoniae
J15.1 - Pneumonia due to Pseudomonas
J18.1 - Lobar pneumonia, unspecified
UTI
N39.0 - Urinary tract infection, site not specified
Skin, soft tissue, bone
L03.1 - Cellulitis of other parts of limb
M72.6 - Necrotizing fasciitis
Sepsis
A41.9 - Sepsis, unspecified
A41.5 - Sepsis due to other Gram-negative organisms
A41.8 - Other specified sepsis
A41.0 - Sepsis due to Staphylococcus aureus
A41.1 - Sepsis due to other specified staphylococcus
A40.8 - Other streptococcal sepsis
J15.0 - Pneumonia due to Klebsiella pneumoniae
A40.9 - Streptococcal sepsis, unspecified
R57.2 - Septic shock
A49.9 - Bacterial infection, unspecified
A41.2 - Sepsis due to unspecified staphylococcus
A40.0 - Sepsis due to streptococcus, group A
A40.3 - Sepsis due to Streptococcus pneumoniae
Abdominal
K57.2 - Diverticular disease of large intestine with perforation and abscess
A04.7 - Enterocolitis due to Clostridium difficile
K63.1 - Perforation of intestine (nontraumatic)
K65.0 - Acute peritonitis
K65.9 - Peritonitis, unspecified
Biliary
K83.0 - Cholangitis
Endocarditis
I33.0 - Acute and subacute infective endocarditis
In conclusion, we captured 96% of infection deaths using just 29 diagnostic codes.
It is thus possible to simplify the analysis of Inada Kim et al considerably,
and by so doing improve the signal to noise ratio of the analysis.
We still included some conditions that are not primarily infective (eg abdominal perforation)
However, this led us to consider that a practical definition of sepsis might be
"A diagnosis for which antibiotics would generally be seen as part of acute management"
The paper only looks at primary codes, and this might miss hospital acquired sepsis.
We agree that this is likely to increase noise, but this is an area that merits further research.
We also note that the authors state “although there are non-bacterial causes of sepsis (eg, viruses, protozoa), these are (generally) far less common and amenable to treatment”
Given that influenza is one of the commonest causes of death from infection, this is perhaps hard to justify.
This will help comparative studies of sepsis management,
and provide focus on the areas that are likely to be benefit from attention.
Iron Deficiency is the most common mineral deficiency worldwide and this review highlights important aspects for clinical care. Firstly and foremost is the astonishing lack of research (and recognition) for a condition that affects 10-15% of all people at any one point in time and a top 10 global cause for years living with disability. Second and pertinant to this specific review is how clinicains should diagnose iron deficiency. The 18 clinical trials listed used the definition of Iron Deficiency used was as a low serum ferritin, which varied from less than 50 to less than 15ug/L. The WHO defines Iron Deficiency as a serum Ferritin < 15ug/L. In athletes the repeated stress of exercise creates inflamation that in turn activates the iron regulation protein, Hepcidin that reduces iron bioavailibility causing a functional iron deficiency. In this setting, Transferrin Saturations (%) may be a more accurate indicator of Iron Deficiency. In the the four studies using Ferritin < 16, Transferrin Saturations averaged over 20% in three, i.e. the majority of individuals may have had potential normal iron. Finally, and along the same theme, in the presence of exercise induced / functional iron defiency oral the effect of oral iron is limited so it is not suprising that iron tablets failed to have an effect. Moving forwards, there is a need to better identify and define Iron Deficiency in the 'healthy' female and further studies with appropriate interventions are need...
Iron Deficiency is the most common mineral deficiency worldwide and this review highlights important aspects for clinical care. Firstly and foremost is the astonishing lack of research (and recognition) for a condition that affects 10-15% of all people at any one point in time and a top 10 global cause for years living with disability. Second and pertinant to this specific review is how clinicains should diagnose iron deficiency. The 18 clinical trials listed used the definition of Iron Deficiency used was as a low serum ferritin, which varied from less than 50 to less than 15ug/L. The WHO defines Iron Deficiency as a serum Ferritin < 15ug/L. In athletes the repeated stress of exercise creates inflamation that in turn activates the iron regulation protein, Hepcidin that reduces iron bioavailibility causing a functional iron deficiency. In this setting, Transferrin Saturations (%) may be a more accurate indicator of Iron Deficiency. In the the four studies using Ferritin < 16, Transferrin Saturations averaged over 20% in three, i.e. the majority of individuals may have had potential normal iron. Finally, and along the same theme, in the presence of exercise induced / functional iron defiency oral the effect of oral iron is limited so it is not suprising that iron tablets failed to have an effect. Moving forwards, there is a need to better identify and define Iron Deficiency in the 'healthy' female and further studies with appropriate interventions are needed to assess functional physical health in this setting.
Dear Sirs,
My research has detected curious patterns of on/off switching in international deaths. Basically, deaths run at a baseline level and then suddenly switch-on to a new and higher level for around 12 to 18 months after which they switch-off and revert back to the baseline. They stay at baseline until the next switch-on event. Deaths in person's with Alzheimer's and other dementias seem highly sensitive to the switch-on events. This curious behaviour is most readily revealed using a rolling (running or moving) 12-month total or average.
In England, in-hospital deaths show the same on/off-switching.
Should you have access to monthly data it may be useful if you could apply such a rolling 12-month analysis of the data.
You can access a list of publications relating to this research at http://www.hcaf.biz/2010/Publications_Full.pdf
I have proposed that this behaviour may reflect some new type or kind of disease outbreak, however, this is open to further research.
I hope this response is helpful.
Decline in neonatal mortality in Northern Ghana: Non-specific effects of BCG vaccination or Improvements in health systems?
In an ecological study carried out in Northern Ghana, Welaga et al., assessed changes in neonatal mortality rates (NMR) and BCG vaccination age from 2002 to 2012. The authors found that among home deliveries, median BCG vaccination age declined from 46 days in 1996 to 4 days in 2012. Within the same period , NMR decreased from 46 to 12 per 1000 live births (1). The authors concluded their study by suggesting that the significant decline in mortality observed may be due to the beneficial non-specific effects of early BCG vaccination. The authors should be commended for studying whether BCG vaccination may have non-specific effects. However, several issues need to be raised when interpreting these results.
Show More1) Adjustment for other vaccine effects
The authors did not expand on the potential role that improvements on the Expanded Programme on Immunization (EPI) in Ghana may have played in reducing neonatal mortality. Diarrhea and Pneumonia are the main causes of neonatal mortality. Although still sub-optimal, Rotac and PCV3 immunization coverage estimates for Ghana in 2012 were significantly better than in 1996 or 2002 (2). A similar trend was observed for almost all the vaccines in the EPI schedule. For example, UNICEF immunization coverage estimates for Ghana indicate that DTP3 vaccine coverage increased from 71 % in 1996 to 92 %...
During the peer review process of this manuscript, it came to our attention that one of the reviewers, Erling Solheim, may have an undeclared conflict of interest. We were told that he had worked in the same research group as the authors from June 2006 to September 2007 and had published research with one of the authors in 2008.
We attempted to contact Erling Solheim a number of times to verify these claims, but he did not respond to our emails at the time. We would like to point out, however, that we do not feel that this undeclared conflict of interest (and one from ten years ago) would have compromised the peer review process or altered our decision to publish the manuscript.
There is much evidence that exposure to various chemicals, such as lead, chromium, tin, mercury, welding fumes, silicon and in particular organic solvents, may cause both brain damage1-3 and chronic kidney disease,4-7 including diabetic kidney disease.8 Therefore, I suggest that the authors, assisted by occupational hygienists, investigate whether their patients are exposed to such chemicals.
References
Show More1. Edling C, Ekberg K, Ahlborg G Jr et al. Long-term follow up of workers exposed to solvents. Br J Ind Med 1990;47:75-82.
2. Kukull WA, Larson EB, Bowen JD et al. Solvent exposure as a risk factor for Alzheimer's disease: a case-control study. Am J Epidemiol. 1995;141:1059-71.
3. Yamanouchi N, Okada S, Kodama K, Sato T. Central nervous system impairment caused by chronic solvent abuse-a review of Japanese studies on the clinical and neuroimaging aspects. Addict Biol. 1998;3:15-27. doi: 10.1080/13556219872317.
4. Zimmerman SW, Groehler K, Beirne GJ. Hydrocarbon exposure and chronic glomerulonephritis. Lancet. 1975;2(7927):199–201.
5. Ravnskov U, Lundström S, Nordén Å. Hydrocarbon exposure and glomeru-lonephritis: evidence from patients’ oc¬cupation. Lancet. 1983;2(8361): 1214–6.
6. Nuyts GD, Van Vlem E, Thys J et al. New occupational risk factors for chronic renal failure. Lancet 1995;346(8966):7–11
7. Ravnskov U. Hydrocarbons may worsen renal function in glomerulonephritis: a meta-analysis of the case-control studies. A...
Where can I find the results to this study? email me either the results or the article please
Dear Editor,
This paper highlights the reasons behind high stillbirth in India. The authors have underlined the importance of recording stillbirths to know the reasons why. Now the need is to translate the conclusions of this study into actions. Immediate action is needed to incorporate the reasons highlighted in this study into modules recently published by National Health Mission like, Induction Training Module for ASHAs in Urban Areas and Guidebook for Enhancing Performance of Auxiliary Nurse Midwife (ANM) in Urban Areas, March 2017. Both of these key modules don't focus on stillbirth and its reasons beautifully highlighted in this study. Translating knowledge into action is the first step in controlling the problem in question and this needs to be done at the earliest opportunity to have safe outcome of pregnancy.
1. From this study, the Authors had the aim to examine trends in prevalence of overweight/obesity among adults in India by socioeconomic position (SEP) between 1998 and 2016 but the data that they collected the range was not the same for example they collected the data 1998/1999, 6 years later 2005/2006, then 9 years later 2015/2016. The data from women they collected start from 1998 and for men start from 2005. From this data, maybe many of researchers will ask about this, it is not clear to describe about the prevalence, around 6 or 9 years it had uniqe graphic that we cannot see from this research.
2. BMI is commonly used by the researcher to classify overweight and obesity in adults. Whereas, BMI is not good enough to describe about nutritional status because BMI does not measure about fat, based on World Health Organization (WHO) Expert Consultation in 2002 to review and assess the issues related to whether population-specific BMI cut-off points are needed in Asian populations. Overweight and obesity are not the same, they have different cut-off. As the Authors mentioned for the overweight the cut-off ≥24,99 kg/m2. Maybe we can distinguish between overweight (≥24,99 kg/m2) and obesity (≥30,00 kg/m2) to see the different of prevalence both of them like the research that Sánchez-Cruz (2018) and Muttarak, Raya (2018) were undertaken from their research. So, Policy makers can know how many adults got overweight and obesity, and this result to be more informative a...
Show MoreComments on Patel et al., Maternal anaemia and underweight as determinants of pregnancy outcomes: cohortstudy in eastern rural Maharashtra, India. BMJ Open. 2018 Aug 8;8(8):e021623. doi: 10.1136/bmjopen-2018-021623
Show MoreDear Sir I have read your above article with great interest and I have to congratulate you on this work.
You investigated an important topic “Anaemia” and its maternal and perinatal outcomes.
As you have mentioned that anaemia is common health problem and it can lead to adverse pregnancy outcomes. I think unlike the other maternal and perinatal outcomes, there are few publish data on association between anemia and cesarean section.1,2
You have mentioned that “The risks of CS and pregnancy-related complications during delivery were significantly higher in non-anaemic women versus anaemic women for both data sets (page 4 the first line in Study outcomes: regression.
These points have also been shown in table 2 in which 20.85%, 23.8% and 29.8% of women with moderate/severe, mild anaemia and non-anaemic women, respectively have cesarean section.
Lower down in table 3 A it have been mentioned that women with severe /moderate anaemia and women with mild anaemia have lower risk of cesarean section (OR= 0.89, 95% CI=(0.84 to 0.95) and OR= 0.91, 95% CI=(0.86 to 0.97), respectively.
I think the reverse might result if you combined both types of anemia severe/moderate and mild together (20.85%+ 23.8%= 44.65%). Then your result wo...
We know that coding of sepsis is poor.
This absence of reliable data makes it hard to compare approaches over time and between locations.
The SoS paper basically lists a lot of codes that the authors associated with infection.
The authors identified 267 codes indicating possible infection.
There were 47475 cases with these codes as a primary diagnosis, with 3440 associated deaths.
We felt that several of these reflected conditions that were not primarily infective in nature
(or at least in which antibiotics would not be a main component of acute management)
We removed the most common of these.
11. N12.X - Tubulo-interstitial nephritis, not specified as acute or chronic
13. J69.0 - Pneumonitis due to food and vomit
54. N10.X - Acute tubulo-interstitial nephritis
62. J84.9 - Interstitial pulmonary disease, unspecified
73. N71.9 - Inflammatory disease of uterus, unspecified
86. K57.1 - Diverticular disease of small intestine without perforation or abscess
90. N48.1 - Balanoposthitis
99. N48.2 - Other inflammatory disorders of penis
130. J69.8 - Pneumonitis due to other solids and liquids
The remaining 258 codes had 45521 cases with 3163 associated deaths.
95% of cases are captured using the first 76 diagnostic codes.
We felt that many of the cases reflected infections that...
Show MoreIron Deficiency is the most common mineral deficiency worldwide and this review highlights important aspects for clinical care. Firstly and foremost is the astonishing lack of research (and recognition) for a condition that affects 10-15% of all people at any one point in time and a top 10 global cause for years living with disability. Second and pertinant to this specific review is how clinicains should diagnose iron deficiency. The 18 clinical trials listed used the definition of Iron Deficiency used was as a low serum ferritin, which varied from less than 50 to less than 15ug/L. The WHO defines Iron Deficiency as a serum Ferritin < 15ug/L. In athletes the repeated stress of exercise creates inflamation that in turn activates the iron regulation protein, Hepcidin that reduces iron bioavailibility causing a functional iron deficiency. In this setting, Transferrin Saturations (%) may be a more accurate indicator of Iron Deficiency. In the the four studies using Ferritin < 16, Transferrin Saturations averaged over 20% in three, i.e. the majority of individuals may have had potential normal iron. Finally, and along the same theme, in the presence of exercise induced / functional iron defiency oral the effect of oral iron is limited so it is not suprising that iron tablets failed to have an effect. Moving forwards, there is a need to better identify and define Iron Deficiency in the 'healthy' female and further studies with appropriate interventions are need...
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