Displaying 1-10 letters out of 532 published
Do not deny parents choice when their baby dies
It is vital that the findings from a recent article published by Redshaw et al are not misinterpreted as evidence that parents should be denied choice after their baby has died. The study reports higher rates of mental health and relationship difficulties among women who held their stillborn baby compared with those who saw but did not hold their stillborn baby.
Sands supports the need for research to understand the impact of a baby's death on families, and we understand the parameters of the study in question. We are concerned, however, that some may suggest, based on these findings, that parents should not hold their dead baby. This would be a retrograde step.
Parents should always be offered the opportunity to see, hold and spend time with their baby. We know, from supporting thousands of parents, that many find great comfort in the memories they create at this time and the opportunity to make their baby a part of their family.
Not all parents will want to hold their baby. It's important that women and their partners should be supported to make the decision that feels most manageable for them in their circumstances, and that this choice is respected.
What's essential is that parents are given genuine choices and time to reflect and decide what they want. Parents should understand they can change their mind and options should be sensitively revisited if appropriate, without giving the impression of pressure.
The recently published 4th edition of Sands' Pregnancy loss and the death of a baby: guidelines for professionals provides clear guidelines on the principles of bereavement care. Sands also provides bereavement care training and many resources to support health professionals working in this area.
It is worth noting that the women and families in the study were recently bereaved, and therefore researchers were only able to ask them to self-report symptoms of anxiety and PTSD at 3 and 9 months after their baby had died. We know at Sands that the impact of the death of a baby lasts many years and changes over time.
Since Sands was founded by a group of bereaved parents in 1978, we have passionately supported parents having the choice over whether to see and hold their baby. We know many long-ago bereaved mothers who were not given this choice, and whose grief was compounded by not being able to not see or hold their own babies.
"I was never allowed to hold our son, only look at him in the incubator. We were not allowed to be with him when he was dying. No photographs taken. Things were very different in 1975." (Patricia Robertson, Argyll and Bute)
"The midwife gently asked me, would you like to see, maybe even hold your baby? My initial reaction was, NO! See, hold a dead thing? NO! But, the midwife knew it could be beneficial for me to see and hold my baby, because she had read the guidance on it in the first edition of the Sands guidelines, and so she asked again. And I did hold my baby and it is the best thing I have ever done in my life. I can remember her weight in my arms, her fat cheeks, her rosebud mouth, her soft hair and I can remember thinking, this is my daughter not something to be afraid of, someone to be proud of." (Steven Guy, Northern Ireland)
What this study importantly highlights is that the death of a baby is a complex and traumatic experience for parents. Given how many women reported poor well-being in the months after their baby's death, their support needs are clearly not being met by current NHS services at what is a very difficult time.
Much more needs to be done in terms of supporting parents both physically and psychologically in the months after the death of their baby. Bereavement and follow up care cannot change the feeling of loss parents may feel, but poor care can compound it.
Clea Harmer, Chief Executive, Sands, www.uk-sands.org
Conflict of Interest:
In Response to Vos and Ravnskov et al.
We would like to thank Vos and Ravnskov et al. for their interest in the points that we raised in our letter to the editor. We welcome scientific exchange, and respect these authors' rights to produce alternate accounts of the veridical world. However, it troubles us that these alternate accounts are in direct conflict with current best evidence.
For example, Eddie Vos states that there has never been a placebo controlled cholesterol-lowering intervention that ended with a mortality benefit in women, and this includes statins. Yet, with respect to women, if he directed his attention to the 2015 paper from CTT in The Lancet, he would learn that statins have the same effectiveness in women and men of equivalent cardiovascular risk in prevention of major cardiovascular events. With respect to the endpoint of all-cause mortality, women and men both had a reduction from statin therapy (women: RR 0.91, 99% CI 0.84- 0.99; men: RR 0.90, 99% CI 0.86-0.95). There was no evidence at all of heterogeneity (p=0.43).1 As for Ravnskov et al.'s response, they seem to have merely reinstated misinterpretations from their paper as rebuttals to our critique of them.
For an appropriate interpretation of evidence on the efficacy and safety of statin therapy, please refer to this link: http://www.sciencedirect.com/science/article/pii/S0140673616313575.
1. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174?000 participants in 27 randomized trials. The Lancet, Volume 385, Issue 9976, 1397-1405.
Conflict of Interest:
A personal response to RtS
I read this article with interest. It was forwarded to me by a colleague who overheard me complaining that my local off licence had recently removed Special Brew under the local RtS scheme.
I would like to describe my own recent experience of the scheme locally.
I felt anxious when I discovered my local off licence no longer stocked Special Brew. This is because it forces me to alter my regular drinking pattern and it has taken away a control mechanism of purchasing single a can each day.
Being a member of the 'hidden' Brew Crew - a moderate, high functioning but nonetheless dependent alcohol user (I even consume my Brew in a wine glass - how middle class is that?!!), a single can gives me the units I require, without the additional fluids that come with weaker beers (and the waking in the night to pee that comes with that) at a price which I can comfortably sustain. I have been a one-can-a-day man for a number of years.
Removing this choice presents me with various consumer dilemmas. If I buy weaker beer, I need more than one can and this increases the price, involves more fluid, sugar, calories and material waste. Besides, more beer actually irritates my stomach - a single can doesn't. This would lead to an increase in units consumed too, along with a hangover and diminished sleep.
Switching to spirits is a possible effective substitution, but only if I am able stick to 4-5 units per night and purchase quantities sufficient to make this cost effective (35cl, 70cl, 100cl). No 10cl appears to exist, which would be perfect. And even if it did, it would inevitably increase expenditure significantly. However, try as I might there is no chance that I would be able to stick to my units with an opened bottle in the house and this always tends to lead to increased consumption.
And so, from a one can a day Special Brew drinker, who has relied upon the product to give me stability over a long period of time, and who is at risk of higher levels of drinking for the reasons described above and who would consider other substance use in a finance / intoxication / impact consideration axis from which other risks inevitably arise, the policy is a total pain.
I'm sure the RtS policy is not intended to cause substance misuse problems or increase expenditure in currently regular drinkers, but in my case both are possible risks.
Conflict of Interest:
Missing important literature
With much interest we read your article about interventions for frequent attenders of healthcare. Unfortunately and wrongly you did not select or review the research on this topic by our Dutch research group. Apparently also the reviewers missed the opportunity to correct this omission. We have already published two reviews on this same topic.(1,2)
(1) Smits FT, Wittkampf KA, Schene AH, Bindels PJ, Van-Weert HC. Interventions on frequent attenders in primary care: a systematic literature review (Provisional abstract). Scandinavian Journal of Primary Health Care, 2008; 26:111-116.
(2) Haroun D, Smits F, van Etten-Jamaludin F, Schene A, van WH, Ter RG. The effects of interventions on quality of life, morbidity and consultation frequency in frequent attenders in primary care: A systematic review. BMC Public Health, 2016:1-12.
Conflict of Interest:
We have realised that one co-author's affiliation is slightly inaccurate.
Dr Rosa Ayesa Arriola's (author 2) affiliation should be as follows:
Department of Psychiatry, Marques de Valdecilla University Hospital, IDIVAL, School of Medicine, University of Cantabria, Santander, Spain. Centro Investigacion Biomedica en Red de Salud Mental (CIBERSAM), Madrid, Spain.
Conflict of Interest:
Physical fitness predicts long-term survival after a cardiovascular event: implications for United Kingdom (UK) Cardiac Rehabilitation
To the Editor
The prognostic importance of cardiorespiratory fitness (CRF) in men and women with coronary heart disease (CHD) has been reported within epidemiological studies (1-3). However, this association has received limited attention within the context of UK Cardiac Rehabilitation (CR) services. We therefore read with interest the recent study published in BMJ Open by Barons and co-investigators (4). The authors examined predictors of long-term survival, including physical fitness, in a cohort study of predominantly post-myocardial infarction patients (mean age 61 years; 86% male) participating in an NHS outpatient CR programme in Basingstoke and Alton, Hampshire, UK. Low baseline CRF (< 13 mL.kg- 1.min-1 for women and < 15 mL.kg-1.min-1 for men) in ~1500 patients estimated by maximal exercise testing was a strong predictor of all-cause mortality (HR 2.47; 95% CI 1.78 to 3.42), relative to a moderate or high CRF level (? 22 mL.kg-1.min-1 for men and ? 19 mL.kg-1.min-1 for women) over 10.7 years follow-up. These findings are timely given the paucity of epidemiological evidence showing long-term outcomes from the UK CR setting. The data from Barons et al. (2015) are consistent with findings from our own long-term, community-based (non-NHS delivery) CR cohort in Leeds, West Yorkshire, UK, recently published in BMJ Open (5). We examined more than 650 participants undertaking extended exercise-based rehabilitation. Routine submaximal, incremental exercise testing found similarly favourable long-term mortality outcomes associated with baseline fitness status. Indeed, estimated submaximal cardiorespiratory fitness (sCRF) level at CR programme entry was the strongest modifiable predictor of long -term survival, surpassed only by older age and other co-existing CV disease. Relative to the lowest fit (bottom 20%) in our cohort; moderate and higher sCRF levels were associated with 40-60% lower risk of death over a median follow-up period of 14 years. Barons and co-workers do not explicitly examine the associations between CRF change during CR and mortality, though report a mean 1.08 MET gain following 40 minutes of once or twice weekly supervised circuit training exercise. This is approximately double the submaximal fitness improvement estimated by Sandercock et al. (6) within 950 patients across four UK CR centres (following twice weekly CR exercise training, over 8 weeks). The estimated short-term sCRF improvement in our cohort was approximately 0.8 MET (24 minutes of supervised training, median 2 sessions per week, over 14 weeks). Thus, collectively these data tend to support the contention that short-term CRF improvements from standard UK CR centres are more modest than that those reported internationally (7). A novel aspect of our study was to estimate risk associated with CR-derived fitness change and the evaluation of this relationship across the sCRF distribution. Importantly, compatible with some prior studies (8, 9) we found the largest sCRF improvements occurred among those with the lowest fitness and a quantifiable reduction in all-cause mortality risk per MET increase achieved during CR. Until now, there has been limited published UK-derived evidence supporting the efficacy of CR in improving mortality outcomes (10-13) and the UK multi-centre clinical trial (14) reported no survival benefit from CR. Importantly however, this trial did not consider CRF changes. Our observation contrasts with recently updated review and meta-analysis (15), which incorporated point estimates from previous UK trials (11-13) and the RAMIT trial of West et al. (14), showing modest, non-significant benefits for all-cause mortality (47 trials: RR: 0.96, 95% CI: 0.88 to 1.04). Similar non-significant findings were also reported in analysis restricted to studies with >3 years follow-up (11 trials: RR: 0.91; 95% CI: 0.75 to 1.10). The inclusion of more recent RCT's, conducted in an era of optimal medical therapy for CHD and within a more varied mix of CHD patients are potential explanations for these non-significant findings. However, as acknowledged by the Cochrane investigators, RCT evidence examining the efficacy of CR is restricted to short-term follow-up of patients (median 12 months) and thus, has inherent limitations for assessing all-cause mortality outcomes. Indeed, in our CR cohort only 13% of participants had died at 10 years, compared to one-third at 14 years. By utilising indirect estimates of aerobic capacity and submaximal fitness data (as opposed to direct respiratory gas analysis) we recognise that both recent UK epidemiological studies (4, 5) cannot precisely quantify patients' individualised CRF or exercise-based improvement. However, our findings are likely to be clinically important, in view of the higher baseline mortality risk of the lowest fit compared to their higher fit counterparts shown in both cohorts. Given that patients in the Basingstoke and Alton cohort were maximally tested, it would have been valuable to see estimated VO2 peak and MET changes from CR associated with long-term outcomes in their cohort. This area remains poorly characterised and data from well-controlled studies of supervised exercise training are required to quantify dose-related improvements in clinical outcomes. Future studies should evaluate an overall measure of exercise dose, or corresponding cardiorespiratory fitness level, which could serve as the basis of a minimal dose recommendation for clinical benefit to better understand the effect of exercise and CRF change on longer-term recurrent CVD and all- cause mortality risk. Together, the study by Barons and co-workers and data from our own extended, community-based CR cohort carry an important public health message about the importance of CRF for long-term (> 10 years) mortality risk in adults with CVD. Both studies demonstrate the more-than- two-fold adverse prognostic risk associated with low CRF fitness levels at entry to CR, and thus corroborate observational data from larger CR cohorts internationally (2, 3, 16). Moreover, our data highlight the substantive long-term survival benefits associated with improving CRF levels through exercise-based CR. Together these data have implications for the delivery of CR and exercise training services. Our findings, in particular, emphasise the importance of promoting CRF improvement through supervised and structured exercise within extended community-based programmes to prolong survival following cardiac events.
References 1. Vanhees L, Fagard R, Thijs L, Staessen J, Amery A. Prognostic significance of peak exercise capacity in patients with coronary artery disease. JACC. 1994 Feb;23(2):358-63. PubMed PMID: 8294687. 2. Kavanagh T, Mertens DJ, Hamm LF, Beyene J, Kennedy J, Corey P, et al. Prediction of Long-Term Prognosis in 12 169 Men Referred for Cardiac Rehabilitation. Circulation. 2002;106(6):666-71. 3. Kavanagh T, Mertens J, Hamm LF, Beyene J, Kennedy J, Corey P, et al. Peak Oxygen Intake and Cardiac Mortality in Women Referred for Cardiac Rehabilitation. JACC. 2003;42(12):2139-43. 4. Barons MJ, Turner S, Parsons N, Griffiths F, Bethell H, Weich S, et al. Fitness predicts long-term survival after a cardiovascular event: a prospective cohort study. BMJ Open. 2015;5(10). 5. Taylor C, Tsakirides C, Moxon J, Moxon JW, Dudfield M, Witte KK, et al. Submaximal fitness and mortality risk reduction in coronary heart disease: a retrospective cohort study of community-based exercise rehabilitation. BMJ Open. 2016;6(e011125). 6. Sandercock GR, Cardoso F, Almodhy M, Pepera G. Cardiorespiratory fitness changes in patients receiving comprehensive outpatient cardiac rehabilitation in the UK: a multicentre study. Heart. 2013 Jun;99(11):785- 90. PubMed PMID: 23178183. 7. Sandercock G, Hurtado V, Cardoso F. Changes in cardiorespiratory fitness in cardiac rehabilitation patients: A meta-analysis. International journal of cardiology. 2011 Dec 27. PubMed PMID: 22206636. 8. Martin B-J, Arena R, Haykowsky M, Hauer T, Austford LD, Knudtson M, et al. Cardiovascular Fitness and Mortality After Contemporary Cardiac Rehabilitation. Mayo Clinic proceedings Mayo Clinic. 2013;88(5):455-63. 9. Mandic S, Myers J, Oliveira RB, Abella J, Froelicher VF. Characterizing differences in mortality at the low end of the fitness spectrum in individuals with cardiovascular disease. European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology. 2010 Jun;17(3):289-95. 10. Bertie J, King A, Reed N, Marshall AJ, Ricketts C. Benefits and weaknesses of a cardiac rehabilitation programme. Journal of the Royal College of Physicians of London. 1992;26(2):147-51. 11. Bethell HJN, Mullee MA. A controlled trial of community based coronary rehabilitation. British heart journal. 1990;64 (6):370-5. 12. Carson P, Phillips R, Lloyd M, Tucker H, Neophytou M, Buch NJ, et al. Exercise after myocardial infarction: a controlled trial. Journal of the Royal College of Physicians of London. 1982;16(3):147-51. 13. Bell JM. A comparison of a multi-disciplinary home based cardiac rehabilitation programme with comprehensive conventional rehabilitation in post-myocardial infarction patients [PhD]: University of London; 1998. 14. West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart. 2012 Apr;98(8):637-44. PubMed PMID: 22194152. 15. Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, et al. Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol. 2016 Jan 5;67(1):1-12. PubMed PMID: 26764059. Epub 2016/01/15. eng. 16. Martin BJ, Hauer T, Arena R, Austford LD, Galbraith PD, Lewin AM, et al. Cardiac rehabilitation attendance and outcomes in coronary artery disease patients. Circulation. 2012 Aug 7;126(6):677-87. PubMed PMID: 22777176.
Conflict of Interest:
Sleep duration, physical activity and television viewing in patients with cardiovascular disease and type 2 diabetes mellitus
I read the article by Cassidy et al. with interest . The authors examined the associations among sleep duration, physical activity and television viewing in adults with special reference to combination of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Adjusted odds ratios (95% confidence intervals) of patients with CVD for low physical activity, high TV viewing and poor sleep duration were 1.23 (1.20 to 1.25), 1.42 (1.39 to 1.45) and 1.37 (1.34 to 1.39), respectively. In addition, adjusted odds ratios (95% confidence intervals) of patients with CVD and T2DM for low physical activity, high TV viewing and poor sleep duration were 1.71 (1.64 to 1.78), 1.92 (1.85 to 1.99) and 1.52 (1.46 to 1.58), respectively. Low physical activity, high TV and poor sleep duration were more prominent in patients with CVD and T2DM by adjusting several confounders. I have some concerns on their study.
First, Patterson et al. examined the associations among sleep duration, physical activity and sedentary behavior in adults . They reported that short and long sleep duration were associated with cardiovascular risk behaviors such as physical inactivity and sedentary behavior. Cassidy et al. categorized short and short sleep duration as "poor sleep duration", and additional lifestyle effects in patients with CVD and/or T2DM existed. I agree with their study result that short and long sleep duration were both risks for CVD and T2DM, although causal association cannot be confirmed by a cross-sectional study.
Second, there is a sex difference on the relationship between Sleep duration and obesity . Li et al. also reported the effect of sleep duration on the incidence of metabolic syndrome (MetS), presenting short and long sleep duration as a risk for MetS in men . In contrast, there was no significant association in females. Cassidy et al. handled a large sample and stratified analysis by sex is recommended for their analyses.
Finally, working status is closely related to sleep duration and lifestyle factors [5,6]. In addition, there is a bi-directional association between short sleep duration and mental health . In any case, further studies are needed to confirm the association between sleep duration, physical activity and television viewing and CVD and/or T2DM by considering several additional variables.
1. Cassidy S, Chau JY, Catt M, et al. Cross-sectional study of diet, physical activity, television viewing and sleep duration in 233,110 adults from the UK Biobank; the behavioural phenotype of cardiovascular disease and type 2 diabetes. BMJ Open 2016;6:e010038.
2. Patterson F, Malone SK, Lozano A, et al. Smoking, Screen-Based Sedentary Behavior, and Diet Associated with Habitual Sleep Duration and Chronotype: Data from the UK Biobank. Ann Behav Med 2016 doi: 10.1007/s12160-016-9797-5
3. Sun W, Huang Y, Wang Z, et al. Sleep duration associated with body mass index among Chinese adults. Sleep Med 2015;16:612-6.
4. Li X, Lin L, Lv L, et al. U-shaped relationships between sleep duration and metabolic syndrome and metabolic syndrome components in males: a prospective cohort study. Sleep Med 2015;16:949-54.
5. Grano N, Vahtera J, Virtanen M, et al. Association of hostility with sleep duration and sleep disturbances in an employee population. Int J Behav Med 2008;15:73-80.
6. Yu E, Rimm E, Qi L, et al. Diet, Lifestyle, Biomarkers, Genetic Factors, and Risk of Cardiovascular Disease in the Nurses' Health Studies. Am J Public Health 2016;106:1616-23.
7. Yoo H, Franke WD. Sleep habits, mental health, and the metabolic syndrome in law enforcement officers. J Occup Environ Med 2013;55:99-103.
Conflict of Interest:
Re: Impact of holding the baby following stillbirth on maternal mental health and well-being: findings from a national survey. BMJ Open 2016;6(8):e010996.
Dear Editor: We were interested in the recent article by Redshaw et al. which reported higher rates of mental health and relationship difficulties among women who held their stillborn baby.1 We agree this is an important topic, but after reviewing the article in depth, we would like to raise several concerns.
(1) We note that this was a retrospective survey with a 30.2% response rate in which just 3% of women did not see and 16% did not hold their baby; these limitations were acknowledged but we believe they also restrict the ability to draw broad conclusions. (2) There was little exploration into the reasons why women did not hold their babies and if they had any regrets about their decisions. While four out of five women reported they did not hold because they could not or did not want to, the study did not account for the fact that women who declined may be fundamentally different at baseline, so that mental health outcomes may be due to underlying differences in mothers rather than their choices or experiences at birth. (3) While the authors emphasize that holding was associated with a trend toward worse mental health outcomes, their actual multivariable analyses show that at 9 months, the only statistically significant difference was higher odds of anxiety. Pre-existing anxiety could contribute to a woman's hesitance to hold the baby after delivery and separately serves as a predictor of postpartum mental health. (4) Even though there are many validated, widely-tested measures to assess postpartum depression,2-5 anxiety,6 and PTSD,7, 8 in both live birth and bereaved mothers, this study used non-validated self-report measures which leads to the need for very cautious interpretation of the results. (5) The factors which have been demonstrated to be strong predictors of postpartum depression and PTSD include prior mental health conditions, interpersonal violence, and lack of social support.9-12 This study did not measure or control for any of these factors. (6) Another issue not addressed in this article is the well-acknowledged preference by parents to be given the option to see or hold their baby and strong evidence that the majority of women are satisfied with their decision.10, 13 Events surrounding the birth of a stillborn baby can have lasting impact on how a mother experiences, remembers, and copes with this event.14 The decision to see or hold a stillborn baby warrants additional investigation, but research must adjust for the known confounders which have been shown to predict development of mental health problems. Moreover, there should be recognition that the experience of a mother at the time of delivery is complex, and multiple pre-existing and intrapartum factors may affect subsequent outcomes and grief.
In summary, we believe it is not possible to reach a conclusion from this study about whether the decision to see or hold a stillborn baby is detrimental or helpful to bereaved parents and urge research to gain a more nuanced understanding of the factors which contribute to parental experiences at the time of delivery and which may influence long-term mental health outcomes. We strongly urge health care providers to continue to offer women the option to hold their stillborn baby, and to make this offer in a respectful, supportive, and normative manner.
No author has any conflicts of interest to declare.
? References 1. Redshaw M, Henderson J. Fathers' engagement in pregnancy and childbirth: evidence from a national survey. BMC Pregnancy Childbirth. 2013;13:70.
2. Myers ER, Aubuchon-Endsley N, Bastian LA, et al. Efficacy and Safety of Screening for Postpartum Depression. Comparative Effectiveness Review 106. Agency for Healthcare Research and Quality Publication No. 13- EHC064-EF. 2013.
3. Boyle FM, Vance JC, Najman JM, Thearle MJ. The mental health impact of stillbirth, neonatal death or SIDS: prevalence and patterns of distress among mothers. Soc Sci Med. Oct 1996;43(8):1273-1282.
4. Ji S, Long Q, Newport DJ, et al. Validity of depression rating scales during pregnancy and the postpartum period: impact of trimester and parity. J Psychiatr Res. Feb 2011;45(2):213-219.
5. Dennis CL. Can we identify mothers at risk for postpartum depression in the immediate postpartum period using the Edinburgh Postnatal Depression Scale? Journal of Affective Disorders. Feb 2004;78(2):163-169.
6. Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: A systematic review. J Clin Psychiatry. Aug 2006;67(8):1285-1298.
7. Youngblut JM, Brooten D, Cantwell GP, Del Moral T, Totapally B. Parent Health and Functioning 13 Months After Infant or Child NICU/PICU Death. Pediatrics. Oct 7 2013.
8. Murphy S, Shevlin M, Elklit A. Psychological Consequences of Pregnancy Loss and Infant Death in a Sample of Bereaved Parents. Journal of Loss & Trauma. Jan 1 2014;19(1):56-69.
9. Cerulli C, Talbot NL, Tang W, Chaudron LH. Co-occurring intimate partner violence and mental health diagnoses in perinatal women. J Womens Health (Larchmt). Dec 2011;20(12):1797-1803.
10. Gold KJ, Leon I, Boggs ME, Sen A. Depression and Posttraumatic Stress Symptoms After Perinatal Loss in a Population-Based Sample. J Womens Health (Larchmt). Mar 2016;25(3):263-269.
11. Gold KJ, Boggs ME, Muzik M, Sen A. Anxiety disorders and obsessive compulsive disorder 9 months after perinatal loss. General Hospital Psychiatry. Nov-Dec 2014;36(6):650-654.
12. Surkan PJ, Radestad I, Cnattingius S, Steineck G, Dickman PW. Social support after stillbirth for prevention of maternal depression. Acta Obstet Gynecol Scand. 2009;88(12):1358-1364.
13. Radestad I, Surkan PJ, Steineck G, Cnattingius S, Onelov E, Dickman PW. Long-term outcomes for mothers who have or have not held their stillborn baby. Midwifery. Aug 2009;25(4):422-429.
14. Lisy K, Peters MD, Riitano D, Jordan Z, Aromataris E. Provision of Meaningful Care at Diagnosis, Birth, and after Stillbirth: A Qualitative Synthesis of Parents' Experiences. Birth. Mar 2016;43(1):6-19.
Conflict of Interest:
Differences by areas and other tests
I would like to know whether the authors ran statistical tests to check whether there have been any differences per geographical area and by deprivation level. If not, it would be worth exploring this further, particularly if there have been changes in prescribing in particular areas. Also, I would recommend running additional statistical tests apart from the Kolmogorov-Smirnov -e.g. the Cramer-von Mises test and the Anderson- Darling test, which under certain conditions have been reported to perform better than the KS.
Conflict of Interest:
Re: Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study. BMJ Open 2016;6(8):e012286.
I read with interest the recently published study by van Welie et al(1) on the effect of combining warning symbols and education on the frequency of erroneously crushing medications in 3 nursing homes in the North of the Netherlands. With an ageing population who are intrinsically predisposed to dysphagia this study is timely.(2) Inappropriate crushing of medicines can pose a clinical risk to patients, so how do nursing staff determine whether a medicine can be crushed? Should we in the first instance conduct an error analysis to establish the cause of erroneous crushing before recommendations for solutions are made? It is known that both systems and individuals contribute to the problem.(3) Could errors be due to:
* Medication orders not being clear that a medicine is modified release, or could pose safety concerns,
* Annotations on medication chart with regards to safe administration not completed by pharmacist,
* References on the crushability of medicines not being readily available to nursing staff,
* Interruption during the medication round leading to a slip,
* Lack of knowledge on how to proceed when for example an order for extended release medicine is prescribed?
In his research van Welie(1) addressed some of these causes by implementing education, placement of posters and addition of warning symbols to medication sachets. This intervention demonstrated a reduction in rate of wrongly crushed medicines being administered from 3.1% to 0.5%.(1)
Could this intervention translate to Australian Residential Aged Care Facilities (RACFs)? Supply of medications to RACFs varies between dispensing of original containers to individually prepared Dose Administration Aids (DDAs), of which there are a number of types utilizing a variety of dispensing systems. Software vendors would need to be engaged to include warning symbols on their labels, and as in the study, widespread education would need to occur.
The symbol provides a warning, notifying nursing staff of non- crushable medicines in a pack. However if only some are non-crushable this requires their identification and removal. Identification of the individual medicine may not be easy despite there being a requirement of colour, shape, size and manufacturer marks on DAA labels in Australia.(4)
In Australian RACFs medications are usually prescribed manually on the National Residential Medication Chart as electronic medication charts are still not prevalent. In Nursing Homes in the Netherlands daily computerized monitoring of all new prescriptions is conducted by pharmacists. This provides increased patient safety and must be developed for Australian patients in the future. In addition there should also be a patient information link alerting to swallowing difficulties.
Multidisciplinary medication review of all patients occurred in this study, which is paramount in ensuring medication safety and is a component of patient care in RACFs.(5) The multidisciplinary team must include a pharmacist, who as the medication expert, will be pivotal in making recommendations when changes to dosage forms are needed especially with patients experiencing swallowing difficulty. In Australia it is best practice and an important safety process for pharmacists to endorse special requirements such as "swallow whole", "do not crush", "Cytotoxic - Use contact precautions" on medication charts to assist with safe administration of medicines, especially as reading of the chart is the last step before medication selection and administration occurs. Until and even when these initiatives are available pharmacists play an important role in keeping the patient safe.
1. van Welie S, Wijma L, Beerden T, et al. Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study. BMJ Open [Internet] 2016[cited 2016 Sep 2];6(8):e012286.Available from: http://bmjopen.bmj.com/content/6/8/e012286.full doi: 10.1136/bmjopen-2016 -012286
2. Aslam M, Vaezi MF. Dysphagia in the Elderly. Gastroenterol Hepatol. [Internet] 2013 Dec[cited 2016 Sep 8];9(12):784-95 Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999993/
3. Leape LL Error in medicine. JAMA [Internet] 1994 Dec[cited 2016 Sep 8];272(23):1851-7 Available from: http://jama.jamanetwork.com.acs.hcn.com.au.monash.idm.oclc.org/data/Journals/JAMA/9292/jama_272_23_039.pdf 4. Australian Pharmaceutical Advisory Council. Guiding principles for medication management in the community. Canberra: Commonwealth of Australia; 2006.[cited 2016 Sep 4] Available from: https://www.health.gov.au/internet/main/publishing.nsf/Content/0A434BB6C6456749CA257BF0001A9578/$File/booklet.pdf
5. Wilson NM, March LM, Sambrook PN, et al. Medication safety in residential aged-care facilities: a perspective. Ther Adv Drug Saf [Internet] 2010 Oct[cited2016 Sep 4];1(1):11-20 Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110799/ doi: 10.1177/2042098610381418
Conflict of Interest: